Penicillin: effect on sodium and potassium transport in bacterial and protoplast forms of Sterptococcus faecalis.

Streptococcus faecalis, incubated in osmotically stabiliz medium in the presence of 1000 units of penicillin per milliliter, accumulated rather than extruded sodium; they accumulated much less potassium than control cells did. These changes were not due to binding of sodium by cell-wall fragments of cells treated with penicillin. Because penicillin had no effect on cation concentrations in stable protoplasts and nongrowing bacterial cells, this effect appeared to be related to the production of the penicillin-induced lesions of the cell wall.

Oxacillin nephritis.

Acute interstitial nephritis secondary to administration of antibiotics is a well-described entity. Oxacillin, however, has never been directly implicated. An 80-year-old man had a rising creatinine level and eosinophiluria while receiving oxacillin sodium. These findings disappeared when use of the drug was discontinued. We conclude that oxacillin is an additional penicillin that can cause interstitial nephritis.

Adult bacteremic Haemophilus parainfluenzae infections. Seven reports of cases and a review of the literature.

Seven cases of adult Haemophilus parainfluenzae infections diagnosed by positive blood cultures are compared with cases previously reported in the English literature. Three patients had pneumonia, while the others had epiglottitis with meningitis, pharyngitis, arthritis, and endocarditis, respectively. Nonendocarditic manifestations of adult H parainfluenzae infection were reported in four other cases. In addition to the diseases of our patients, H parainfluenzae also has been isolated from cerebral abscesses. Patients did well with antibiotic therapy and there were no deaths. Patients did well with antibiotic therapy and there were no deaths. Report of antibiotic sensitivity testing of 50 strains disclosed 6% of isolates resistant to ampicillin sodium, with all sensitive to chloramphenicol. If the antibiotic sensitivity of the organism is unknown, then chloramphenicol therapy should be instituted until adequate susceptibility studies have been performed. If the organism is sensitive to ampicillin, then this is the drug of choice.

Chronic progressive coccidioidal pneumonitis. Report of six cases with clinical, roentgenographic, serologic, and therapeutic features.

Chronic progressive coccidioidal pneumonitis (CPCP) is an uncommon sequela of acute pulmonary coccidiodomycosis. Six recent patients with CPCP are described, most of whom were previously healthy. The clinical presentation was indolent, resulting in long diagnostic delays. Serial chest roentgenograms showed progressive pulmonary infiltration and sputum cultures were persistently positive for Coccidioides immitis. Serum complement fixation (CF) antibody titers were high, with five of six patients having titers greater than or equal to 1:16. No patients had evidence of extrapulmonary coccidioidal spread at time of diagnosis of CPCP, although hematogenous dissemination occurred later in one patient. Five patients received amphotericin B intravenously (greater than or equal to 30 mg/kg total), resulting in rapid clinical and mycologic cure, decline in CF titers, and roentgenographic improvement or stabilization. However, two of these five patients suffered permanent physiologic impairment. One patient refused therapy and remains clinically symptomatic, with chronic positivity of sputum cultures for C immitis and high CF titers.

Group D enterococcal meningitis. Clinical and therapeutic considerations with report of three cases and review of the literature.

Three patients with meningitis due to the Lancefield group D enterococci are described and the pertinent literature is reviewed. Anatomic central nervous system (CNS) defects, prior neurologic or neurosurgical interventions, group D enterococcal endocarditis, and urinary tract infection appear to be important predisposing factors. Of note is the frequent lack of cellular response in the spinal fluid to enterococci. The mortality of this infection is high (33%) and is probably dictated as much by the underlying disorder as the infection itself. The therapeutic importance of careful separation of group D streptococcal isolates into enterococci and nonenterococci, especially in instances of CNS infections, is emphasized. We discuss the appropriate antimicrobial therapy for enterococcal meningitis.

Therapeutic regimens for anorectal gonococcal infection in males.

Anorectal gonococcal infection is particularly prevalent in women and homosexual men. Although the currently recommended Public Health Service therapeutic regimens for uncomplicated gonorrhea appear to be effective also for anorectal gonorrhea in women, their efficacy for anorectal infection in men has not been adequately evaluated. We report a case of gonococcal proctitis in a homosexual man that did not respond to therapy with ampicillin plus probenecid and tetracycline, but subsequently responded to spectinomycin therapy. Currently available therapeutic regimens for anorectal gonococcal infection in males are reviewed.

Non-group D streptococcal meningitis misidentified as enterococcal meningitis. Diagnostic and therapeutic implications of misdiagnosis by screening microbiology.

Two patients had nonhemolytic Gram-positive coccal meningitis. Both pathogens were initially misidentified as a group D enterococcus by growth in "selective" media, which led to the use of inappropriate and potentially toxic systemic and intrathecal aminoglycosides. Careful evaluation of the antibiotic sensitivity data and additional microbiological studies allowed correct identification of the organism. The important diagnostic and therapeutic considerations in differentiating true enterococcal infections, especially meningitis, from those caused by other alpha-hemolytic or nonhemolytic streptococci are emphasized. A simple laboratory schema for rapid recognition of such pathogens is reviewed.

Sternoarticualr pyoarthrosis due to gram-negative bacilli. Report of eight cases.

Of eight patients with Gram-negative bacillary sternoarticular pyoarthrosis, seven were long-term intravenous heroin abusers. Clinical onset was insidious and a long delay (one month or more) in seeking hospitalization was usually noted. Anterior chest discomfort and painful, restricted homolateral shoulder motion were the chief complaints. Fever and monoarticular arthritis were universally present, Open synovial biopsy examination was frequently required for etiologic diagnosis. Pseudomonas aeruginosa was the most common pathogen isolated. Roentgenographic evidence of associated osteomyelitis was usually seen, but tomography was often necessary to delineate this lesion. Intraoperatively, associated osteomyelitis of the clavicular head and/or sternum was present in all eight cases and a perisynovial and/or retrosternal abscess was found in five patients. Early surgical exploration and prolonged antimicrobial therapy yielded excellent results.

Infective endocarditis following human-to-human enterococcal transmission: a complication of intravenous narcotic abuse.

Two heroin addicts, husband and wife, who shared injection paraphernalia extensively, developed enterococcal endocarditis within six weeks of one another. The etiologic organisms were of the same subspecies and had identical antibiotic susceptibilities and biochemical profiles. The clinical, epidemiologic, and bacteriologic data strongly suggest human-to-human transmission of the pathogen.

Candida meningitis. Report of seven cases and review of the english literature.

Seven patients with Candida meningitis are reported. These 7, plus 21 previously cited cases, were reviewed. This infection arose by two distinct mechanisms: hematogenous dissemination and direct inoculation. Recent antibiotic therapy, corticosteroid administration and severe underlying diseases were important predisposing factors. Fever, meningismus, elevated CSF pressures and localizing neurologic signs were commonly noted. Organisms were seen on gram-stain of CSF in only 43% of cases. Mortality rate in patients receiving inadequate or no antifungal therapy was high (greater than 90%), while those patients given appropriate antifungal drugs, especially intravenous amphotericin B, had a significantly lower mortality rate (38%). Several factors associated with poor prognosis were delineated in this study: diagnostic interval after symptomatic onset longer than two weeks, CSF glucose levels below 35 mg/100 ml and presence of intracranial hypertension and focal neurologic deficits.

Role of anaerobic bacteria in spontaneous peritonitis of cirrhosis: report of two cases and review of the literature.

The role of anaerobic or microaerophillic bacteria in spontaneous peritonitis of cirrhosis has not been clearly defined. Among 126 cases recorded in the literature, in only eight (6 per cent), including the two reported here, was bacterascites associated with anaerobic or microaerophilic bacteria. Clinical features in these cases were indistinguishable from those associated with aerobic bacteria. However, polymicrobial bacterascites occurred in four of eight cases associated with anaerobes, as contrasted with only 10 of 118 cases (8 per cent) associated with aerobes alone. On the other hand, concurrent bacteremia occurred in only one of eight cases associated with anaerobes as contrasted with 52 of 118 cases (44 per cent) of aerobic spontaneous peritonitis. Experimental evidence is cited in an attempt to explain this relatively low incidence of spontaneous peritonitis associated with anaerobic or microaerophilic bacteria, despite the high density of these organisms in the normal bowel flora.

Role of anaerobic bacteria in subdural empyema. Report of four cases and review of 327 cases from the English literature.

Anaerobic bacteria were isolated from the subdural space in all four cases of subdural empyema encountered over a 2 and a half year period. Only one aerobe was isolated in these cases. The bacteriology of subdural empyema was further analyzed from a review of 327 cases reported in the English literature. Anaerobes accounted for 12 per cent of 234 cases; In addition, 27 per cent of cases were reportedly "sterile." These data support our finding that anaerobic bacteria may play a far more important role in subdural empyema than was previously appreciated.

Lactobacillemia--report of nine cases. Important clinical and therapeutic considerations.

Serious infections due to lactobacilli have been rarely cited. We report our findings in nine recent patients with lactobacillemia. In the combined literature and current experience, endocarditis and sepsis from localized suppuration were the most common clinical syndromes, most frequently arising from prior oropharyngeal infections. Lactobacillus endocarditis showed a predilection for left-sided cardiac involvement (100 per cent) and systemic arterial embolization (55 per cent). The nine clinical isolates were tested for minimal inhibitory and bactericidal concentrations (MICs and MBCs) against five drugs with broad gram-positive spectrums; of note, these organisms demonstrated a high incidence of both unachievable MBCs (64 per cent) and widely disparate (greater than 100 fold) MIC:MBC ratios (38 per cent). This is in accord with observations in Lactobacillus endocarditis of poor in vivo clinical response despite "appropriate" regimens and achievable MICs of the organisms. Bactericidal synergistic studies on two endocarditis isolates indicated that the penicillins plus aminoglycosides may be potentially useful in the treatment of deep-seated Lactobacillus infections when single antimicrobials fail to achieve a cure.

Sepsis associated with decubitus ulcers.

Among 21 patients with sepsis attributed solely to decubitus ulcers, bacteremia was documented in 16 (76 per cent)9 Bacteremia involved obligate anaerobes in eight patients (50 per cent) and was polymicrobial in eight patients (50 per cent). Twelve of 17 patients who received antibiotics had persistent bacteremia; in five patients, bacteremia was terminated only after surgical debridement. Ten of these 21 patients died, eight despite appropirate antibiotics. Among 14 patients who underwent surgical debridement, only four patients died. Surgical debridement and antibiotics effective against aerobic as well as anaerobic bacteria are both important in the treatment of this serious complication.

Hematogenous candida osteomyelitis. Report of three cases and review of the literature.

Candida osteomyelitis of the spine and intervertebral disc developed in three patients without evidence of back trauma of overlying cutaneous infection. Two patients were prone to the development of disseminated candidiasis by the use of multiple antibiotics and other predisposing modalities following abdominal surgery. One patient had no identifiable cause for development of the infection. The diagnosis was established in all three cases by x-ray evidence of osteomyelitis and culture from needle aspirate. Two patients had bone scans consistent with infection. Each patient received different therapy. One was treated with amphotericin B, one with spinal fusion and 5-fluorocytosine, and one with no antifungal therapy. All patients had complete healing of the involved vertebrae. Candida organisms have the potential to cause destructive bone infection following hematogenous dissemination. The presence of Candida osteomyelitis may be helpful in diagnosing disseminated candidiasis.

Cytomegalovirus mononucleosis in a healthy adult: association with hepatitis, secondary Epstein-Barr Virus antibody response and immunosuppression.

A 35 year old previously healthy physician had clinical manifestations of a mononucleosis illness complicated by arthralgia, vesicular pharyngitis and hepatitis. Initially, the patient had cytomegalovirus (CMV) viremia (predominantly in polymorphonuclear leukocytes) followed by the presence of CMV in the urine, throat and semen. He also had an antibody response to the Epstein-Barr virus which appeared to be a secondary type. During the acute phase of illness, only 7 per cent of the patient's lymphocytes formed spontaneous T cell rosettes as compared to a normal value of 65 to 70 per cent. Concurrently, evidence of abnormal delayed hypersensitivity was manifested by the loss of reactivity to mumps skin test antigen. All clinical and laboratory abnormalities except for the persistence of CMV in the pharynx, urine and semen returned to normal after resolution of the clinical illness.

Serious infections in adults due to group B streptococci. Clinical and serotypic characterization.

Serious infections in adults due to group B streptococci have been infrequently reported. We describe 24 such patients. Bacteremic pyelonephritis, pneumonitis and endometritis were the most common clinical syndromes observed. Group B streptococci infections tended to occur in patients with underlying illnesses, particularly genitourinary disorders and diabetes mellitus. Mortality was surprisingly low (8 per cent). Type III was the serotype most commonly isolated, and there was no significant correlation of different serotypes with specific organ-system involvement. Group B streptococcal isolates from these patients were uniformly sensitive to penicillin, ampicillin, cephalothin, chloramphenicol, erythromycin and clindamycin; all were highly resistant to kanamycin. Eighty-seven per cent were resistant to tetracycline. Although consistently sensitive to penicillin, the minimal inhibitory concentrations were significantly higher for group B than group A streptococci (p less than 0.0005).

Necrotizing pneumonia and empyema due to Clostridium perfringens. Report of a case and review of the literature.

Clostridia are rare causes of pleuropulmonary infections in the absence of penetrating chest injuries; only 10 previous cases have been reported from civilian practice. An additional case of a rapidly progressive, necrotizing pneumonia and empyema is reported. Clostridial pneumonia is more likely to occur in patients with underlying pleuropulmonary disease. Unlike clostridial myonecrosis, it is rarely associated with toxemia; its mortality rate is comparable to that of nonclostridial pleuropulmonary infections. Appropriate antimicrobial therapy with surgical drainage of the empyema is the treatment of choice. Among the cases reviewed, an iatrogenic cause of infection involving an invasive procedure into the pleural cavity could be identified in seven of 11 cases. Aspiration of oropharyngeal contents was the likely route of infection in three other cases. In the remaining case, bacteremic seeding of the pleural cavity was the most probable mode of infection.

Use of circulating immune complex levels in the serodifferentiation of endocarditic and nonendocarditic septicemias.

Distinguishing endocarditic from nonendocarditic septicemias is prognostically and therapeutically important. One hundred two patients with both valvular and nonvalvular sepsis were studied for the presence and quantitation of circulating immune complexes. Ninety per cent of the patients with infective endocarditis versus 50 per cent of septic patients without infective endocarditis had circulating immune complex levels (p less than 0.005). Mean circulating immune complex levels in patients with infective endocarditis were significantly higher than in those without infective endocarditis, 106 +/- 18.58 microgram/ml versus 31 +/- 7.4 microgram/ml (p less than 0.005). Only three of 52 patients without infective endocarditis had circulating immune complex levels greater than 100 microgram/ml, as opposed to 16 of 50 patients with infective endocarditis (p less than 0.005). Similarly, one of 52 patients without infective endocarditis has circulating immune complex levels greater than 200 microgram/ml, as opposed to eight of 50 patients with infective endocarditis (p less than 0.05). In 92 per cent of the patients without infective endocarditis and 76 per cent of those with infective endocarditis peak circulating immune complex levels developed within 14 days after their entry into the study, often on the initial sampling. In febrile, septicemic patients with clinical symdromes nonclassic for endocarditis, measurements of serial circulating immune complex levels may be of adjunctive diagnosis importance. If circulating immune complex levels are undetectable, endocarditis would appear less likely; alternatively, levels above 100 to 200 microgram/ml would suggest a valvular rather than nonvalvular septic focus.

Candida peritonitis. Report of 22 cases and review of the English literature.

Thirty-one patients with Candida isolated from peritoneal fluid were examined. Twenty-two were considered to have Candida peritonitis. The data on these 22 patients, plus 12 additional patients described in the literature, were reviewed. This infection was observed as a complication of peritoneal dialysis, gastrointestinal surgery or perforation of an abdominal viscus. Recent antibiotic administration seemed to be an important predisposing factor. The disease usually remained localized intra-abdominally, although disseminated candidiasis was also noted in three cases. Clinically significant infection could be differentiated from peritoneal contamination with Candida by the presence and persistence of fever, peritoneal signs, peripheral leukocytosis, positive peritoneal cultures for Candida, abnormal films of the abdomen and purulent ascitic fluid. Surgical interventions and removal of infected peritoneal fluid were the cornerstones of therapy. Short-term, low-dose systemic and/or intraperitoneally administered amphotericin B appeared promising in the treatment of unremitting infection. Mortality in treated patients was low and was comparable to that in patients with bacterial peritonitis.