Early switch from intravenous to oral cephalosporins in the treatment of hospitalized patients with community-acquired pneumonia.

BACKGROUND: Switch therapy is defined as the early transition from intravenous to oral antibiotics during treatment of infection. This study was designed to evaluate the clinical outcome and length of stay of hospitalized patients with community-acquired pneumonia treated with an early switch from intravenous to oral third-generation cephalosporins. METHODS: Patients with a new roentgenographic pulmonary infiltrate and at least two symptoms (cough, fever, or leukocytosis) were enrolled in this study and treated with intravenous ceftizoxime sodium (1 g every 12 hours) or ceftriaxone sodium (1 g every 24 hours). Patients were switched to oral cefixime (400 mg every 24 hours) as soon as they met the following criteria: (1) resolution of fever; (2) improvement of cough and respiratory distress; (3) improvement of leukocytosis; and (4) presence of normal gastrointestinal tract absorption. RESULTS: Of the 120 patients enrolled, 75 (62%) had clinical data evaluated. Long-term follow-up showed that 74 patients (99%) were cured; one patient required readmission for further intravenous therapy. Mean duration of hospital stay was 4 days. CONCLUSIONS: This investigation demonstrated that an early switch to oral cefixime may be reasonable in hospitalized patients with community-acquired pneumonia who have already shown a good clinical and laboratory response to therapy with intravenous third-generation cephalosporins. This approach is clinically effective and minimizes hospital stay.

Acute miliary blastomycosis in an AIDS patient.

The incidence of blastomycosis in immunocompromised patients with HIV infection is very low when compared to other mycoses. Of the 19 cases of blastomycosis described in HIV-infected patients, only four had a miliary pattern on chest x-ray. A case of acute miliary blastomycosis in an HIV infected patient from Louisville is described.

HIV-negative "AIDS" in Kentucky: a case of idiopathic CD4+ lymphopenia and cryptococcal meningitis.

Here we describe a case of unexplained CD4+ T-lymphocyte depletion and cryptococcal meningitis in a patient without evidence of human immunodeficiency virus (HIV) infection. This newly recognized syndrome has been named idiopathic CD4+ lymphopenia (ICL). When HIV infection is suspected in a patient with an opportunistic infection, a CD4+ lymphocyte count should be obtained, even if the patient's HIV test is negative. Patients with persistently low CD4 counts (< 300 cells/microL, or < 20%) who show no evidence of HIV infection, who have no defined immunodeficiency, and who are not receiving therapy associated with CD4 depletion have disease that meets the definition of ICL, and the case should be reported to the Centers for Disease Control.

Lemierre's syndrome: postanginal sepsis due to anaerobic oropharyngeal infection.

Lemierre's syndrome is an uncommon clinical entity. It consists of oropharyngeal infection and anaerobic bacteremia, followed by jugular vein septic thrombophlebitis with embolization to lungs and other areas. Although it occurs less frequently than in the pre-antibiotic era, it is important that the typical presentation be recognized because of its lethal potential. A case of Lemierre's syndrome in Louisville, Kentucky, is described.

Comparative study of the bactericidal activity of ampicillin/sulbactam and erythromycin against intracellular Legionella pneumophila.

Intracellular bactericidal activity of ampicillin/sulbactam and erythromycin was determined with a human macrophage-like (U-937) cell line infected with Legionella pneumophila. Cell monolayers inoculated with L. pneumophila were treated with erythromycin, ampicillin, sulbactam, or ampicillin/sulbactam during the logarithmic phase of bacterial growth. Intracellular bacterial counts were determined at 2-h intervals for 8 h from the time that antibiotics were added. The number of viable intracellular bacteria increased during this time by 0.9 x log10 cfu/mL (P < 0.05) in the control culture, did not change significantly in the cultures treated with ampicillin or sulbactam, decreased by 0.8 x log10 cfu/mL (P < 0.05) with erythromycin, and decreased by 1.8 x log10 cfu/mL with ampicillin/sulbactam (P < 0.05). The number of cfu/mL was significantly less after incubation with ampicillin/sulbactam than with erythromycin (P < 0.05). Ampicillin/sulbactam appeared to have greater bactericidal activity against intracellular L. pneumophila than erythromycin in this in-vitro model. The bactericidal action of ampicillin/sulbactam was significantly greater than would be expected from the additive effects of ampicillin plus sulbactam, suggesting synergic bactericidal activity.

Increased rate of tuberculin skin test conversion among workers at a university hospital.

OBJECTIVES: To summarize the results of an investigation of increased rates of tuberculin skin test conversion in employees at a university hospital. DESIGN: The results of annual tuberculin skin tests performed on all 1,845 hospital employees from 1986 to 1991 were reviewed. SETTING: A 450-bed acute tertiary care university hospital. RESULTS: The rate of tuberculin skin test conversion was 0.35% (standard deviation +/- 0.15) from 1986 to 1989 and increased to 1.7% during 1991. Investigation revealed deviations from the Centers for Disease Control (CDC) guidelines for tuberculosis control, which included the failure to consider tuberculosis as a probable cause of community-acquired pneumonia and the failure to initiate isolation precautions when tuberculosis was suspected. CONCLUSIONS: The epidemic appeared to be secondary to delays in diagnosis and isolation of patients with pulmonary tuberculosis. Future control measures should include isolation of all hospital patients admitted with pneumonia until tuberculosis has been excluded.

Bactericidal activity of imipenem compared to erythromycin against intracellular Legionella pneumophila.

Pneumonia is the leading cause of death due to nosocomial infections with mortality ranging from 30 to 70%. Because imipenem has potent in vitro activity against virtually all major causes of nosocomial pneumonia, including P. aeruginosa, S. aureus, members of the family Enterobacteriaceae, and anaerobic organisms, it is used by many physicians as the empirical therapy of choice in severe nosocomial pneumonias. Recognition of Legionella species as nosocomial pathogens has been increasing. The incidence of Legionnaires' disease among patients with nosocomial pneumonia is reported to be as high as 30% (1), but the real prevalence is unknown. Imipenem has bactericidal activity against Legionella in vitro but has not previously been tested for efficacy against intracellular Legionellae.

Absence of bacteremia during nasal septoplasty.

Episodes of staphylococcal bacteremia resulting in metastatic infection have occurred in association with nasal septoplasty, and this has suggested the possible need for antimicrobial prophylaxis. In a study designed to measure the actual frequency with which transient staphylococcal bacteremia occurs during nasal septoplasty, 50 healthy patients had blood cultures drawn immediately prior to and during the procedure. Although 46% of the 50 patients studied had their nasal mucosa colonized with Staphylococcus aureus, some of the blood cultures obtained from the 50 patients showed bacterial growth. The authors conclude that staphylococcal bacteremia during nasal septoplasty is a rare occurrence, and that antimicrobial prophylaxis is unnecessary.

The high rate of noncompliance for post-vasectomy semen examination: medical and legal considerations.

The records of 1,029 consecutive patients undergoing bilateral vasectomy were reviewed. Of the 1,029 patients 375 (36%) never returned postoperatively and the partners of 2 of these 375 later became pregnant. A total of 560 patients (54%) was followed until the recommended demonstration of azoospermia occurred on 2 consecutive occasions. There were 84 patients (8%) who did not return after the first demonstration of azoospermia, while 7 (1%) still had sperm in the semen at the last examination. Three other patients had persistent nonmotile sperm postoperatively; 2 of them underwent repeat vasectomy followed by azoospermia and 1 was placed in a special clearance category of sterility as described. We discuss practical and legal considerations regarding the management of noncompliant patients.

PIP: Urologists reviewed the medical charts of 1029 consecutive patients who had experienced a bilateral vasectomy (cauterization of the mucosa at each end and of the divided vas deferens) at the University of Louisville's School of Medicine in Kentucky between February and December 1986 to examine the medical and legal ramifications of vasectomized men not returning to have physicians examine their semen. Only 54.4% of the men returned for the recommended 2 semen examinations. 8.2% returned only once. 7 men (1% of the 654 who returned for semen examination) had sperm in their last semen sample. 36.4% (375) did not return at all after the vasectomy. Partners of 2 of these men conceived. 1 pregnancy occurred 29 months postoperatively. The men did not want to have his semen examined, however, for fear of learning he was sterile. The other pregnancy occurred 67 months after the vasectomy and the man's sperm had many motile sperm. Late recanalization of the vas deferens most likely occurred in this case. Other than recommending to patients before and during the vasectomy to submit 2 semen samples after the vasectomy, the urologists had no mechanisms in place to assure compliance. The high noncompliance rate in this study made the researchers consider their new legal responsibilities. Court cases for somewhat related medical situations have resulted in the jury finding the physician negligent because he/she did not fully inform the patient of the risk of noncompliance. Thus physicians, even though they may believe they are not responsible for noncompliance, should prudently inform patients of their risk of not complying by perhaps sending a punctually written notice. These warnings may protect them from potential litigation. Nevertheless the courts may appropriate more responsibility of patient actions to the physicians than is either morally justified or reasonable.

Primary Vibrio vulnificus sepsis in Kentucky.

Vibrio vulnificus is associated with infection acquired during contact with sea water or with seafood, and is seldom suspected by physicians in noncoastal states. The ease of transportation of fresh raw seafood has facilitated this organism's capacity to produce disease in geographic areas in which it was previously unseen. We have reported a case of fatal Vibrio vulnificus sepsis acquired from ingestion of fresh oysters in the inland United States.

Interactions of virulent and avirulent Legionella pneumophila with human monocytes.

Four pairs of virulent/avirulent strains of Legionella pneumophila were examined for their adherence/uptake and activation of human monocytes. Oxidative metabolic responses of monocytes were quantitated by measuring intracellular hydrogen peroxide generation using flow cytometry and by assessment of superoxide dismutase-inhibitable superoxide anion generation. All L. pneumophila strains induced less of a response than did Escherichia coli. Within each pair of isolates, virulent strains of L. pneumophila stimulated the oxidative response of monocytes less than avirulent variants. To determine effects of complement fixation by each strain on their adherence to monocytes, a phagocytic index (PI) was determined under various conditions. In autologous donor serum (AS), all L. pneumophila strains had a PI in the range of 2.1-3.1 bacteria per monocyte, with E. coli having a PI of 9.1. No significant differences were observed between virulent L. pneumophila strains and their avirulent variants. In the presence of heat-inactivated AS, all PI fell to 0.13-0.20 for the L. pneumophila strains, and to 2.16 for E. coli. Using heat-inactivated AS reconstituted with exogenous human complement as a source of opsonization, levels of PI were indistinguishable from their respective levels in AS. This suggests that complement fixation plays an important role in the adherence of virulent and avirulent L. pneumophila to human monocytes.

Interactions of virulent and avirulent Legionella pneumophila with human polymorphonuclear leukocytes.

Isogenic virulent/avirulent variants of Legionella pneumophila (Lp) were examined in vitro for their effect on PMN function as determined by measurement of peak chemiluminescence and superoxide anion production. When exposed to virulent/avirulent strains of Lp, PMN function was less than that seen following exposure to E. coli, the reduction of the oxidative burst being more pronounced with virulent Lp strains in both assays. To determine whether differences in reduced PMN function correlate with differences in complement component C3 binding by virulent and avirulent Lp, four pairs of organisms were incubated in normal human serum and examined by quantitative immunofluorescence. All strains of Lp bound less C3 than E. coli, although each to different degrees. Avirulent isogenic strains bound more C3 than their virulent counterparts with one exception. Depressed PMN function following exposure to Lp may be due to reduced C3 binding, although other virulence-associated factors may be involved.

Effect of the topical application of some newer antibiotics on the cerebral cortex.

Five currently used antibiotics--moxalactam, cefotaxime, cefoperazone, metronidazole, and piperacillin--and bacitracin were compared for epileptogenetic effect against penicillin G as a standard when applied directly to cat cerebral cortex. Piperacillin was half as epileptogenic as penicillin. Moxalactam, cefotaxime, and cefoperazone showed epileptogenicity one-fourth to one-eighth that of penicillin on a milligram per cubic centimetre basis. Neither metronidazole nor bacitracin produced any focal seizure activity at the highest concentrations tested. Some of the newer cephalosporin antibiotics may have a significant risk of inducing seizure activity if high concentrations come in direct contact with neocortical tissue.

Brain abscess. A study of 45 consecutive cases.

Clinical features, findings of diagnostic studies, results of therapy, and prognostic factors were analyzed in 45 patients with brain abscesses. The number of patients diagnosed yearly has increased since CT scanning became available, but despite the enhanced sensitivity, the time from either onset of symptoms or hospital admission until initiation of therapy was not decreased and there was no dramatic effect upon morbidity or mortality in this series. Infections of paranasal sinuses, ears, lungs, and odontogenic foci were predisposing factors in approximately 70% of cases. Single abscesses, present in 75% of patients, were distributed equally in both hemispheres, with more than half in the frontal and parietal lobes. Common signs and symptoms included headache, fever, chills, seizures, nausea, vomiting, altered sensorium, nuchal rigidity, and localizing neurologic signs. Blood cultures were positive in 11%. Lumbar puncture rarely provided data from which a diagnosis could be established; CSF cultures were positive in only 7% of patients, and there was a 15% temporally associated incidence of brain herniation and death. Diagnostic information was most readily obtained using imaging techniques such as CT and 99mTc scanning, and arteriography was invasive and of no added value. CT scans are however, often initially negative in patients presenting with clinical signs of meningitis presumably following rupture of an abscess into the subarachnoid space, and the average time for changes to appear on CT scan is 9 days. It is, therefore, recommended that when the clinical assessment suggests the possibility of brain abscess the patient be treated empirically with antibiotics and that lumbar puncture be performed only after thoughtful assessment of the risk-to-benefit ratio for each patient. Causative organisms were isolated from more than 80% of abscesses despite prior antibiotic treatment; more than half grew a single pathogen, most commonly streptococci. Anaerobic and microaerophilic bacteria accounted for 62% of all isolates, and were the only organisms in 33% of patients. Computerized tomographic scans in 30 patients showed "ring-enhancing" lesions, nodular enhancement, or areas of low attenuation. Complete resolution of abscesses on CT scans rarely occurred during hospitalization and took as long as 5 months. Decrease in the size of abscesses on CT scan correlated well with clinical improvement and was seen within a week when abscesses were excised, but was often not obvious for 6 to 8 weeks if antibiotics were used alone.(ABSTRACT TRUNCATED AT 400 WORDS)

Endogenous aspergillus endophthalmitis.

A 27-year-old man with a history of intravenous-narcotic abuse presented with signs and symptoms suggesting fungal endophthalmitis. He underwent core vitrectomy with intravitreal injection of amphotericin B. Aspergillus flavus grew from cultures of the vitreous aspirate. There was no evidence of extraocular infection, and the patient was treated postoperatively with subconjunctival amphotericin B and oral flucytosine. Unlike previously reported cases of endogenous aspergillus endophthalmitis in drug abusers, the patient described here recovered normal visual acuity.

The in vitro effects of methotrexate on the phagocytosis and intracellular killing of Staphylococcus aureus by human neutrophils.

The in vitro effect of therapeutic concentrations of methotrexate on the phagocytosis and intracellular killing of Staphylococcus aureus by circulating human neutrophils was assessed. Neutrophils were isolated from whole blood of six healthy human volunteers by density centrifugation and incubated with 10(-3) M methotrexate. Staphylococcus aureus was opsonized in human serum and added to the prepared neutrophils. Phagocytosis was determined by serial dilutions and plating of unphagocytized bacteria. After treatment with lysostaphin and trypsin, intracellular killing of bacteria was determined at set intervals by serial dilutions and platings of viable bacteria released by neutrophil lysis. Methotrexate-treated neutrophils phagocytized 56% and control neutrophils 67% of bacteria in 15 minutes (P greater than 0.5), and 96% of ingested bacteria were killed in 15 minutes by both populations. In these experiments, the in vitro incubation of circulating human neutrophils with methotrexate produced no significant alterations in neutrophilic phagocytosis or intracellular killing of S. aureus.

Aspergillus osteomyelitis. Report of a case and review of the literature.

Aspergillus is a ubiquitous saprophytic fungus seldom pathogenic for normal hosts. Aspergillus osteomyelitis occurs infrequently and is typically limited to patients with predisposing factors, including leukocyte dysfunction, malignancy with neutropenia, steroid or antibiotic therapy, pulmonary aspergillosis, and surgical manipulation. The spine is most frequently affected, and the clinical presentation is nonspecific (50% afebrile). Diagnosis requires demonstration of characteristic, acutely branching, broad, septate hyphae in biopsy material, and culture of Aspergillus. Therapy includes debridement of necrotic bone and loculated purulence combined with amphotericin B and possibly 5-fluorocytosine or rifampin.

Rhabdomyolysis associated with pneumococcal sepsis.

A case of pneumococcal sepsis associated with rhabdomyolysis is reported. Rhabdomyolysis is a rare complication of bacterial infections not directly involving muscle. Eleven cases of rhabdomyolysis associated with bacteremic infections were found in the literature and clinical data are summarized. The pathogenesis and frequency of this association remains unknown.

Septoplasty complicated by staphylococcal spinal osteomyelitis.

Surgery for correction of anatomic abnormalities of the nasal septum is usually free of major infectious complications. A case of staphylococcal spinal osteomyelitis as a consequence of bacteremia induced by nasal septoplasty is reported and the questions raised by this occurrence are discussed.