Multiple drug-resistant Chlamydia trachomatis associated with clinical treatment failure.

In vitro susceptibility testing and genotyping were done on urogenital isolates of Chlamydia trachomatis from 3 patients, 2 of whom showed evidence of clinical treatment failure with azithromycin and one of whom was the wife of a patient. All 3 isolates demonstrated multidrug resistance to doxycycline, azithromycin, and ofloxacin at concentrations >4.0 microg/mL. Recurrent disease due to relapsing infection with the same resistant isolate was documented on the basis of identical genotypes of both organisms. This first report of clinically significant multidrug-resistant C. trachomatis causing relapsing or persistent infection may portend an emerging problem to clinicians and public health officials.

Anaerobes in pelvic inflammatory disease: implications for the Centers for Disease Control and Prevention's guidelines for treatment of sexually transmitted diseases.

In preparing the 1998 sexually transmitted disease treatment guidelines of the Centers for Disease Control and Prevention, we reviewed evidence regarding the need to eradicate anaerobes when treating pelvic inflammatory disease (PID). Anaerobes are present in the upper genital tract during an episode of acute PID, with the prevalence dependent on the population under study. Vaginal anaerobes can facilitate acquisition of PID and cause tissue damage to the fallopian tube, either directly or indirectly through the host inflammatory response. Use of several broad-spectrum regimens appears to result in excellent clinical cure rates, despite the fact that some combinations fall short of providing comprehensive coverage of anaerobes. There are limited data on the long-term effects of failing to eradicate anaerobes from the upper genital tract. Concern that tissue damage may continue when anaerobes are suboptimally treated has prompted many experts to caution that therapeutic regimens should include comprehensive anaerobic coverage for optimal treatment of women with PID.

Pathology of hyalohyphomycosis caused by Scedosporium apiospermum (Pseudallescheria boydii): an emerging mycosis.

The genus Scedosporium contains two medically significant species of emerging mycotic agents, S. apiospermum and S. prolificans, which have received scant attention. Scedosporium apiospermum is the anamorph, or asexual state, of the cosmopolitan fungus Pseudallescheria boydii, with both sharing the same risk factors for infection, clinical spectrum, and histopathologic features. Scedosporium prolificans is a recently recognized agent of bone, soft tissue, and joint infections that occurs with highest frequency in children and young adults. S. prolificans may also cause potentially fatal disseminated infections in immunocompromised persons. The drug sensitivities of both Scedosporium species are significantly different from those of most other fungi, and thus identification of these organisms is important. Unfortunately, the pathological features of Scedosporium infections may be easily confused with other mycotic agents, resulting in delayed or inappropriate medical therapy. Because many pathologists and clinicians are unfamiliar with the significance of Scedosporium spp. infection, this communication describes three persons with differing clinical and pathological presentations of S. apiospermum infection. In one patient with sickle cell disease and chronic mycotic sinusitis, fungal colonies of S. apiospermum removed from the sinuses showed a pattern of alternating zones of mycelial hypercellularity and hypocellularity associated with conidiation, similar to a previous report of P. boydii infection. The clinicopathologic features of an immunocompetent person with S. apiospermum osteomyelitis, and a patient with S. apiospermum infection of the brain after bone marrow transplantation, are also described.

Enterococcal arthritis: case report and review.

We report a case of septic arthritis due to Enterococcus species and review 18 additional cases reported in the literature from 1966 through 1993 for which clinical or treatment data were available. In 11 of the 19 cases, prosthetic joints were affected (9 knees, 2 hips) and in 8 cases, native joints were affected. Of those patients with prosthetic joint infections, 6 had preexisting osteoarthritis and 3 had rheumatoid arthritis; only one patient with native joint infection had a recognized (although unspecified), preexisting joint abnormality. Pain, fever (temperature, > 37 degrees C), and tenderness were the most common clinical findings in patients with native joint infections. The microbiological diagnosis was made by culture of synovial fluid or synovial tissue (16 of 19), blood (1 of 19), or an unstated specimen (2 of 19). Polymicrobial infection was present in 6 (32%) of 19 patients. Of fourteen patients treated with either a parenteral penicillin (11 of 19) or a glycopeptide (3 of 19), 11 made an uncomplicated recovery. An aminoglycoside was also used to treat 7 of these 14 patients (4 of these 7 had prosthetic joints). All 11 prosthetic joint infections were ultimately clinically cured; for most of these patients, the original prosthesis was removed. For two patients with native joint infections, amputation of the infected limb was necessary to cure the infection.

Clinical manifestations of genital infection due to Chlamydia trachomatis in women: differences related to serovar.

The relationship between the infecting Chlamydia trachomatis serovar and the clinical manifestations of genital tract infection was evaluated in a study of 155 women attending a sexually transmitted diseases clinic; 99 women had lower genital tract infection and 56 had Chlamydia-associated pelvic inflammatory disease (PID). In the group with lower genital tract infection, women with serovar F differed from those with serovars of class B or C in that they exhibited fewer signs of cervical infection, including easily induced bleeding (P = .04), edema of the zone of cervical ectopy (P = .06), and colposcopic evidence of mucopurulent endocervical discharge (P = .007). Serovar F also produced fewer infections with inclusion counts of > or = 1,000 and fewer rectal infections (P = .04). There was no apparent association of any specific serovar with PID. Thus, in this population, serovar F was associated with fewer objective clinical manifestations of mucopurulent endocervical discharge, and the distribution of chlamydial serovars found in PID reflected that found in lower genital tract infection.

Long-term eradication of Chlamydia trachomatis genital infection after antimicrobial therapy. Evidence against persistent infection.

OBJECTIVE: To determine whether Chlamydia trachomatis urogenital infections persist or relapse after antimicrobial therapy by serial measurement of chlamydial-specific DNA using the polymerase chain reaction (PCR), cell cultures, and serological studies. DESIGN: Prospective evaluation of an inception cohort. SETTING: University student health clinic. PARTICIPANTS: Twenty women with culture-proven and PCR-proven C trachomatis urogenital infections. MEASUREMENTS: Incidence of persistent infection as determined by PCR, culture, and serial measurement of local and systemic antibody to C trachomatis for 5 months after doxycycline therapy. RESULTS: Prior to therapy, C trachomatis was isolated in cell culture from the cervix in 19 of 20 women, from the urethra in 13 women, and from the rectum in 13 women. All culture-positive specimens were also PCR-positive. Immediately after completion of antimicrobial therapy, all women had negative cell cultures for chlamydia. Ten of 20 culture-negative cervical specimens and two culture-negative urethral specimens had chlamydial DNA present immediately after treatment. In addition, three women had detectable DNA from cervical specimens 1 week after treatment. The presence of cervicitis (P = .01), high inclusion counts (P = .004), and serological evidence of recent infection (P = .0004) were each significantly associated with PCR positivity after treatment. All 384 subsequent cervical, rectal, and urethral specimens collected over 5 months were negative by both PCR and culture with the exception of one woman who was reinfected. Serum immunoglobulin M (IgM) titers, geometric mean serum immunoglobulin G (IgG) titers, and prevalence of local antibody to chlamydia progressively declined after treatment. CONCLUSIONS: Standard antimicrobial therapy is effective in the long-term microbiologic eradication of uncomplicated C trachomatis urogenital infections. The presence of chlamydial DNA after antimicrobial therapy is of short duration and reflects excretion of nonviable organisms rather than persistent infection.

Association of genital infection with specific Chlamydia trachomatis serovars and race.

Black race is an important risk marker for Chlamydia trachomatis genital infection. To define whether C. trachomatis serovars differ by ethnic distribution, a panel of monoclonal antibodies was used to serotype 934 urethral and 581 cervical isolates from patients attending a sexually transmitted diseases clinic over 2 years. The overall serovar distribution in cervical and urethral infections was comparable, with B class serovars predominating. Significantly higher inclusion counts were observed both in younger women and in nonblacks regardless of serovar. Serovar D was less frequent among blacks at the urethral site (P = .001), while serovar Ia was more frequent in blacks at both sites (urethral, P < .001; cervical, P = .02). These associations remained significant after adjusting for age and number of inclusion-forming units by multivariate analysis. Thus, specific serovars may be associated with particular racial groups; either behavioral or biologic factors could explain these findings.

Systemic Bacillus species infection mimicking listeriosis of pregnancy.

Bacillus species are increasingly recognized as agents of infection in humans. These organisms are ubiquitous in nature and can cause clinical illness ranging from transient bacteremia to serious systemic infection. We describe a pregnant intravenous drug abuser with fever, constitutional symptoms, and premature labor. Her blood cultures yielded gram-positive bacilli, and her clinical course was consistent with systemic listeriosis of pregnancy. Pathological examination of the placenta revealed acute villitis, and Bacillus species grew from cultures of both placenta and blood. Through biochemical testing the isolate was identified as Bacillus pumilis. To our knowledge, this is the first reported case of premature labor induced by Bacillus species infection.