The spectrum of Mycobacterium kansasii disease associated with HIV-1 infected patients.

Louisiana is known to be an area endemic for Mycobacterium kansasii (MK). Since MK tends to disseminate in immunocompromised patients, one might, therefore, expect to observe an increasing number of MK infections associated with human immunodeficiency virus (HIV-1). A systematic 60-month review of clinical, microbiologic, and radiographic data associated with MK was performed from two major referral centers in New Orleans. From June 30, 1983 through June 30, 1988, MK was isolated from 72 patients. Twenty-three of the 72 (31.9%) were found to be coinfected with HIV-1. Over the 5-year study period, the phenomenon of dual infection increased from 0 to 50%. Six cases of extrapulmonary infection were found among the HIV-1 patients as compared to 1 in 49 non-HIV patients (p = 0.003, Fisher's exact test). In addition, patients with dual infection had atypical chest radiographs, usually with interstitial infiltrates without cavitation. Most of these patients died within 12 months (90.9%). When treatment was administered at all, often it varied considerably from patient to patient despite the well-known in vitro efficacy of certain widely available anti-mycobacterial agents.

Cryptococcus neoformans pulmonary infection in HIV-1-infected patients.

Cryptococcus neoformans (Cn) is a frequent pathogen in patients infected with the human immunodeficiency virus (HIV-1). We review the initial presentation and clinical course of 18 HIV-1-infected (HIV+) patients with a Cn pulmonary infection. Simultaneous positive cerebrospinal fluid (CSF) cultures were found in 10 (63%) of 16 examined. The most frequent presenting symptoms were fever (87%) and pulmonary complaints (60%). Although the most common chest radiographic finding was bilateral diffuse interstitial infiltrates, nodules and cavitary lesions were also seen. Nine (50%) of the 18 patients died within 6 weeks of diagnosis. Of six patients with an isolated Cn pulmonary infection, five have subsequently died. Three of these five patients did not receive maintenance therapy and had confirmed or probable relapse. Patients initially presenting with an isolated Cn pulmonary infection may later show disseminated disease, suggesting that such patients should receive both acute and maintenance therapy.

Overview of bacterial infections of the skin and soft tissue and clinical experience with ticarcillin plus clavulanate potassium in their treatment.

The etiology, diagnosis, and treatment of skin and soft tissue infections are discussed, and the results of clinical experience with ticarcillin plus clavulanate potassium in these diseases at one clinic are reported. In a randomized and controlled clinical trial, the safety and effectiveness of ticarcillin plus clavulanate potassium and cefazolin were compared in the treatment of soft tissue infections in 20 patients. The 12 patients in the group treated with ticarcillin plus clavulanate potassium included 10 men and two women, with a mean age of 61 years; the eight patients in the group treated with cefazolin were five men and three women, with a mean age of 63.8 years. Ticarcillin plus clavulanate potassium was administered for four to 26 days (mean 12.5 days), and cefazolin for four to 20 days (mean 12 days). There were 29 evaluable pathogens in the group receiving ticarcillin plus clavulanate potassium and 22 in the group receiving cefazolin. Of the 29 pathogens in the former group, 22 were eradicated; three reinfections or superinfections occurred but were ultimately eradicated, and four pathogens persisted. Eighteen of the 22 pathogens in the cefazolin-treated group were eliminated and the other four persisted. Clinically, six of the 12 patients in the ticarcillin plus clavulanate potassium-treated group had cures, four showed improvement, and two failed to show a response. In the cefazolin-treated group, five of the eight patients had cures, one showed improvement, and two failed to show a response.

Dermatologic manifestations of nosocomial infections.

There is no substitute for preventing dermatologic infection in a hospitalized patient by maintaining intact, well nourished skin. The integrity of the integument becomes assaulted on a daily basis from a variety of methods. Measures to lessen this risk can be undertaken, but it may not be totally preventable. The phenomenon of infected desquamated squamous cells being dispersed into the environment by patients and health care workers is one that deserves further study. If this proves to be an important factor, hospital spread of bacteria may indeed be unavoidable. It is hoped that this review will serve as a starting point in an area short on clinical data. Further study into this arena is clearly needed.

Comparison of the in vitro activity of ciprofloxacin and 24 other antimicrobial agents against clinical strains of Chromobacterium violaceum.

Eleven clinical strains of Chromobacterium violaceum were tested for their susceptibility to 25 antimicrobial agents. Ciprofloxacin was the most active of the compounds tested although norfloxacin and pefloxacin were highly active. No resistance was detected to mezlocillin, piperacillin, apalcillin, imipenem, and aztreonam while a single strain was resistant to ticarcillin. Among the cephalosporin/cephamycin group only cefotetan showed good in vitro activity. Gentamicin was more active than amikacin and tobramycin. Good in vitro activity was also noted for chloramphenicol, doxycycline, and trimethoprim-sulfamethoxazole while C. violaceum strains were highly resistant to rifampin and vancomycin. The bactericidal activity of selected agents was shown to be concentration dependent using time-kill kinetic studies. Addition of clavulanic acid did not increase the activity of ticarcillin and in one case was shown to induce beta-lactamase. High correlation was noted between the broth microdilution and disk diffusion susceptibility tests in predicting the susceptibility patterns of C. violaceum.

Choosing antimicrobials. Factors to consider, available agents.

Many factors are involved in choice of an antimicrobial agent. Cost has become a matter of increasing concern. Of course, overall expense for the hospitalized patient includes costs of tests for monitoring for toxicity as well as administration costs, which are affected by the dosing frequency. A reasoned choice necessitates knowledge of the place of newer agents in the therapeutic armamentarium and of some new applications of well-established drugs.

Surrogate markers for survival in patients with AIDS and AIDS related complex treated with zidovudine.

OBJECTIVE: To determine whether early effects of zidovudine treatment on CD4+ lymphocyte count and concentrations of beta 2 microglobulin, neopterin, or HIV p24 antigen or antibody are correlated with survival in patients with AIDS or AIDS related complex. DESIGN: Retrospective study of changes in laboratory markers and survival. SETTING: Multicentre trial at university hospital clinics. SUBJECTS: 90 Patients with AIDS or AIDS related complex. INTERVENTION: Patients started zidovudine 200 mg orally every four hours. Fifty six of the patients died a median 17 months after starting zidovudine; the remaining 34 patients were followed up for a median 25.5 months. MAIN OUTCOME MEASURES: Changes in CD4+ lymphocyte count and serum concentrations of p24 antigen and antibody, beta 2 microglobulin, and neopterin; survival of the patient. RESULTS: The pretreatment characteristics that independently predicted poor survival were determined using a multivariate proportional hazards model: a diagnosis of AIDS (v AIDS related complex), age over 45 years, and the logarithm of serum neopterin concentration. When these baseline characteristics were controlled for the logarithm of CD4+ lymphocyte count at weeks 8-12 of treatment (p = 0.007) and an increase in serum beta 2 microglobulin concentration at weeks 8-12 (p = 0.05) also independently correlated with survival. In the 38 patients with a better pretreatment prognosis, 24 month survival estimated by the product-limit method was 88% for those with a good response on both surrogate markers during early treatment compared with only 50% for those with a poor response on either marker. In the 38 with a worse pretreatment prognosis, 24 month survival was estimated to be 49% for those with a good response on both surrogate markers compared with only 18% for those with a poor response on either. CONCLUSION: These data suggest that CD4+ lymphocyte count at 8-12 weeks and, perhaps, change in serum beta 2 microglobulin concentration could be surrogate end points for clinical outcome in trials of antiretroviral drugs for patients with HIV disease.

Hepatitis C experience at a community teaching hospital.

BACKGROUND: The purpose of this study was to review the initial serologic testing experience for hepatitis C (HCV) and physician response at a community teaching hospital. METHODS: A retrospective chart review was performed for the 59 (5%) HCV-positive patients of 1244 patients who were tested by means of a new enzyme immunosorbent assay (EIA) for HCV antibodies between October 28, 1990, and October 27, 1991. RESULTS: Physicians identified HCV risk factors, including intravenous drug use (n = 14, 25%) and having received blood products (n = 15, 27%). One half of the patients were not queried about the known risk factors for HCV. The most common reason for ordering an HCV assay was elevated liver enzymes. None of the patients underwent supplementary HCV testing (ie, polymerase chain reaction or recombinant immunoblot assay). In 23 (40%) of the HCV-positive patients, no action was taken by the physician, and 15 (27%) were lost to follow-up. The remaining 18 patients (33%) had further follow-up with laboratory or treatment. CONCLUSIONS: These results indicate the need for increased physician awareness of risk factors for HCV and improved documentation of these factors in taking patient history. In addition, primary care physicians need to be educated about new laboratory tests and how to interpret test results and when to order supplemental testing.

The role of bacterial cultures from bronchoscopy washings in AIDS related patients.

The clinical significance of bronchoscopy washing cultures for bacteria had been questioned before the era of the acquired immune deficiency syndrome (AIDS), and the procedure was felt to be misleading more than helpful. Little has been mentioned of its utility in AIDS patients undergoing fiberoptic bronchoscopy. The correlation of these cultures was retrospectively reviewed for 30 bronchoscopies performed in 26 patients with advanced AIDS related illnesses. Normal respiratory flora was the most common finding in 14/28 (50%) of the cultures submitted, followed by Staphylococcus aureus in 7/28 (25%). Correlating chest radiographs with culture results revealed that in only five cases were cultures definitely or possibly relevant. All five had radiographic changes compatible with bacterial processes, and clinical findings suggestive of disease. The routine submission of bronchoscopy washings for bacterial culture in patients with HIV associated disease should be discouraged without clinical and radiologic correlation.

Botryomycosis caused by Serratia marcescens.

We have reported a case of lymph node botryomycosis caused by Serratia marcescens, which has not been listed previously as an etiologic agent.

Streptococcus pneumoniae endocarditis presenting as an epidural abscess.

Streptococcus pneumoniae is an important pathogen in many serious infections, such as pneumonia, sinusitis, and meningitis. It uncommonly causes infective endocarditis and only rarely produces spinal epidural abscesses. This report describes a patient who had pneumococcal infection presenting as an acute epidural abscess and who was subsequently found to have endocarditis. S. pneumoniae was cultured from both blood and abscess material. A high level of clinical suspicion of endocarditis is important in all cases of bacteremic pneumococcal illness; patients with such an illness and back pain may harbor potentially catastrophic epidural abscesses.

Candida albicans infected pseudocyst in a postpartum woman.

We have presented the case of a postpartum woman with a pseudocyst infected with C albicans and have reviewed the relevant literature. The patient did well with surgical drainage of the pseudocyst and adjunctive therapy with amphotericin B. Candida species isolated from a pancreatic pseudocyst or abscess should be considered pathogens, and the patient should receive aggressive therapy.

Spectrum of Cryptococcus neoformans infection in 68 patients infected with human immunodeficiency virus.

Sixty-eight patients infected with human immunodeficiency virus (HIV) and Cryptococcus neoformans who presented to three major medical centers in New Orleans, Louisiana, were studied retrospectively. In patients with meningitis the most common presenting symptoms were fever and headache. Those without central nervous system involvement generally had an isolated pulmonary infection due to C. neoformans and presented with cough and dyspnea. CSF parameters were abnormal in 41% of patients, and the India ink preparation was positive in 88% of patients with cultures of CSF positive for C. neoformans. The overall median survival time for the 47 patients who died was 5 months, with a range of 0-22 months. Of the 27 patients who received maintenance therapy with amphotericin B, two (7%) relapsed. The only factors found to be associated with a poor prognosis were abnormal computed tomography of the head and altered mental status on presentation. C. neoformans infections in HIV-infected patients remain difficult to treat and have a poor prognosis.