Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals.

Antimicrobial resistance results in increased morbidity, mortality, and costs of health care. Prevention of the emergence of resistance and the dissemination of resistant microorganisms will reduce these adverse effects and their attendant costs. Appropriate antimicrobial stewardship that includes optimal selection, dose, and duration of treatment, as well as control of antibiotic use, will prevent or slow the emergence of resistance among microorganisms. A comprehensively applied infection control program will interdict the dissemination of resistant strains.

Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals.

Antimicrobial resistance results in increased morbidity, mortality, and costs of health care. Prevention of the emergence of resistance and the dissemination of resistant microorganisms will reduce these adverse effects and their attendant costs. Appropriate antimicrobial stewardship that includes optimal selection, dose, and duration of treatment, as well as control of antibiotic use, will prevent or slow the emergence of resistance among microorganisms. A comprehensively applied infection control program will interdict the dissemination of resistant strains.

Human granulocytic ehrlichiosis in the upper Midwest United States. A new species emerging?

OBJECTIVE: To characterize the clinical presentation and course, laboratory findings, and treatment outcome of 12 patients with human granulocytic ehrlichiosis. SETTING: The 12 patients were male, ranged in age from 29 to 91 years, and contracted their illness in Wisconsin or Minnesota. METHODS: Cases were recognized by the presence of intracytoplasmic inclusions (morulae) in peripheral neutrophils of patients presenting with temperature of 38.5 degrees C or higher, chills, severe headache, and myalgias. All patients had a complete blood cell count and blood chemistry profile. Blood smears were examined by light microscopy. All available paired serum samples were analyzed for presence of indirect fluorescent antibodies against Ehrlichia chaffeensis, Ehrlichia phagocytophila, and Ehrlichia equi. Blood samples from 12 patients were subjected to polymerase chain reaction analysis using primers specific for the E phagocytophila/E equi group, primers that include the agent identified in our patients, as well as E chaffeensis. RESULTS: Varying combinations of leukopenia, anemia, and thrombocytopenia were found in all but one patient. All 12 patients demonstrated morulae in the cytoplasm of neutrophils, but not in mononuclear white blood cells. Serum assays failed to detect antibodies against E chaffeensis, but eight of 10 patients and seven of 10 patients tested had antibody titers of 1:80 or more for E phagocytophila and E equi, respectively. Polymerase chain reaction products obtained with primers for E phagocytophila, E equi, and the granulocytotropic Ehrlichia revealed that seven patients were infected with the same agent. The results of serological assays or polymerase chain reaction strongly suggest that all 12 patients were infected by E phagocytophila, E equi, or a closely related Ehrlichia species. Two of the 12 patients died. The other 10 patients improved rapidly with oral doxycycline treatment. CONCLUSIONS: We believe that all 12 patients have been infected with a granulocytic Ehrlichia species, reflecting a recently described new disease entity. The infective organism appears to be closely related to E phagocytophila and E equi. The geographic domain of human granulocytic ehrlichiosis is currently unknown. This novel granulocytic Ehrlichia species is capable of causing fatal infections in humans. Early detection and treatment with tetracycline drugs appear to offer the best chance for complete recovery.

Treatment of coccidioidal meningitis with fluconazole.

Fluconazole was administered at doses of 50-400 mg/d to 18 patients (15 men, three women) with coccidioidal meningitis. After a mean duration of treatment of 9.8 months, 10 (67%) of 15 assessable patients had responded, one (7%) of 15 had partially responded, and four (27%) of 15 had not responded to therapy. Five (63%) of eight assessable patients receiving fluconazole as sole therapy responded or partially responded. Two patients discontinued fluconazole after initially responding to therapy, and both experienced relapse. The toxicity of fluconazole remains minimal at doses to 400 mg/d. The penetration of fluconazole into cerebrospinal fluid is substantial at all doses studied. Thus fluconazole continues to show promise even as sole therapy against coccidioidal meningitis. Not all patients respond, however, and relapse may be a problem with the currently studied doses and durations of therapy.

Babesiosis in Wisconsin. A new focus of disease transmission.

A confirmed case of human babesiosis was identified in August 1983 in a 54-year-old asplenic Wisconsin resident. Babesia microti was identified as the causative agent by blood smear morphology and hamster inoculation techniques. The patient's wife had clinically confirmed Lyme disease in 1981 and had serologic evidence (immunofluorescent antibody to a B microti titer of 1:1,024) of recent Babesia infection in August 1983. Mice (Peromyscus species) trapped on the patients' property and elsewhere in their Wisconsin county of residence were infected with B microti. Lyme disease and babesiosis have the same tick vector and animal reservoir; serum samples from 116 Wisconsin and Minnesota residents with clinically confirmed Lyme disease between 1980 and 1983 were tested, and none were found to have concurrent Babesia infection. This area of Wisconsin is identified as a new focus for babesiosis transmission, but the risk of transmission seems to be low.

Prevalence and laboratory identification of methicillin-resistant Staphylococcus aureus in community hospitals.

The prevalence of methicillin-resistant Staphylococcus aureus infections in community hospitals in northern Minnesota, Wisconsin, and Michigan was found to be one case in 82,565 patients. The percentage of S. aureus isolates resistant to methicillin was less than 0.2% (5 of 2,835). In this study, conducted from 1 June 1982 to 31 May 1983, a laboratory-controlled methodology was used.

Blastomycosis in immunosuppressed patients.

Of 78 patients with blastomycosis, 3 patients had received glucocorticoid therapy prior to diagnosis and 3 others had an underlying hematologic malignancy (chronic lymphocytic leukemia, chronic myelogenous leukemia, multiple myeloma). The clinical picture in these 6 patients was similar to blastomycosis in nonimmunosuppressed patients (in contrast to histoplasmosis or coccidioidomycosis in immunosuppressed patients in whom a distinct clinical syndrome is often seen). The patients presented with chronic pulmonary infiltrates or with isolated skin ulcers. The response to therapy was good if the diagnosis was made early. Blastomycosis can occur in immunosuppressed patients. However, the spectrum of underlying illness is not that seen in opportunistic histoplasmosis or coccidioidomycosis, where patients with T-cell defects predominate. Possible explanations for the rarity of blastomycosis in more classically T-cell-immunosuppressed patients are discussed.

Chronic blastomycotic meningitis.

Three cases of blastomycosis which presented as chronic meningitis are reported. Blastomycotic meningitis is an uncommon form of chronic fungal meningitis and is difficult to diagnose during life unless the patient has obvious systemic blastomycosis elsewhere. Evaluation of cerebrospinal fluid obtained by lumbar tap is usually not diagnostic. Obstructive hydrocephalus developed in all three patients during the course of their fungal meningitis. Culture of ventricular fluid yielded the fungus in all three patients (although only after death in one case). One patient received only minimal therapy before death whereas the third patient received a full course of amphotericin B with restoration to his premorbid state. Blastomycosis should be included in the differential diagnosis of chronic meningitis and, when suspected, the cisternal or ventricular fluid should be sampled.

Self-limited blastomycosis: a report of thirteen cases.

Blastomycosis is not generally recognized to be a self-limited pulmonary infection. We report 13 patients with blastomycosis who followed a self-limited course. Presenting complaints were usually those of an acute pulmonary infection with fever, productive cough, and pleurtiic chest pain. The duration of symtpoms before diagnosis was usuallms were variable and not diagnostic. The blastomycin skin test and complement-fixing serologies to blastomycin were generally not helpful. In all patients the diagnosis was made by either cultural or visual identification of the organism from sputum, bronchial washings, or pleural fluid. All patients were improving both clinically and by chest roentgenograms by the time the diagnosis was reached, and thus therapy was withheld. Follow-up of these 13 patients ranged from 5 months to 8 yr (mean, 43 months), and in no instance has there been any evidence of reactivation of the illness.

Canine blastomycosis as a harbinger of human disease.

Blastomycosis occurred in six patients in five households. In each instance one or more dogs living with the family or living near the family also developed blastomycosis. The recognition of canine blastomycosis helped in the early diagnosis of human cases. Because both dogs and patients were probably infected at the same place, canine blastomycosis may be an important epidemiologic marker, alerting physicians to the possible presence of concomitant blastomycosis in humans.

Bacterial endocarditis caused by Oerskovia turbata.

Oerskovia turbata is a yellow, motile actinomycete, which before now has only been found in soil and has not been known to cause disease in man or animals. It was isolated from 29 cultures of blood taken during 6 months from an urban pensioner after homograft replacement of his aortic valve. The combination of ampicillin, sulfamethoxazole, and trimethoprim was lethal for O. turbata in vitro; however, antimicrobial therapy alone failed to eradicate the patient's infection. Cure was achieved after the infected homograft was replaced with a prosthetic aortic valve. Although the source of O. turbata in this patient is unknown, sterilization of homograft valves with antimicrobial solutions is difficult. Moreover, environmental contamination during cardiopulmonary bypass is common. Oerskovia turbata is another opportunistic pathogen of man.

Brucellosis linked to Mexican cheese.

Three cases of brucellosis occurred, two acute cases and one chronic, all of which likely resulted from the ingestion of fresh cheese containing Brucella melitensis. A history of patients with illness suggestive of brucellosis should include details about food ingested recently in addition to the usual questions about travel and occupation. As the US domestic-animal disease comes under better control, and travel to Mexico, Spain, and Italy increases, it seems likely that human disease caused by B melitensis will become relatively more common.