Disseminated coccidioidomycosis. Unusual manifestations in a cardiac transplantation patient.

Because of the immunosuppressive therapy received by patients undergoing cardiac transplantation, disseminated infections, including disseminated fungal infections, often develop. Disseminated coccidioidomycosis developed in a 23-year-old man soon after undergoing orthotopic cardiac transplantation. Clinical manifestations included an unusual rash, severe myositis and arthropathy, a rapid downhill course, and pathologic evidence of widespread fungal invasion, including invasion of the cardiac graft. Detailed travel and geographic histories, and perhaps skin testing and antibody determinations for geographic-specific pathogens, should be part of the preoperative evaluation of all transplant candidates.

Coryneform group A-4 endophthalmitis. An experimental animal model.

Diphtheroids, members of the coryneform family of bacteria, increasingly have been recognized as the cause of serious ocular diseases. After isolation of coryneform group A-4 from two patients with delayed endophthalmitis after cataract extraction and intraocular lens implantation, 10(7) organisms were injected into the vitreous of seven New Zealand white rabbits, producing endophthalmitis in all eyes inoculated. Coryneform group A-4 subsequently was isolated in six of seven eyes receiving 10(7) organisms, proving Koch's postulates. Five of these seven eyes were treated with a single dose of intravitreal gentamicin, and three eyes remained culture positive. Eyes inoculated with 10(5) or 10(2) coryneform group A-4 organisms had transient anterior chamber and vitreal inflammation; all vitreous cultures were negative. These studies demonstrate that coryneform group A-4 endophthalmitis can be reproduced in an animal model and that gentamicin may not sterilize an eye infected with this organism. Future studies are needed to determine the optimum antibiotic regimen for treatment of this type of endophthalmitis.

Coryneform endophthalmitis. Two case reports.

Recent clinical studies have emphasized the importance of diphtheroids, previously regarded as nonpathogenic bacteria or contaminants, as causes of ocular disease. We encountered two patients with endophthalmitis following cataract extraction and anterior chamber intraocular lens implantation. Both patients had previously been treated with subconjunctival and/or oral corticosteroids for presumed sterile endophthalmitis. Vitreous cultures in each case yielded pure growth of a diphtheroid that was subsequently identified as coryneform group A-4. The clinical response to standard intraocular therapy with gentamicin and cefazolin was delayed, although both patients eventually had restoration of functional vision. A comparison of the antibiotic minimum inhibitory and minimum bactericidal concentrations of the isolates may help to explain the delayed response to therapy seen in these two patients.

Detection of Chlamydia trachomatis in genital specimens by the Microtrak direct specimen test.

The conventional cell culture method for detection of Chlamydia trachomatis requires two to six days and is technically difficult to perform. The authors evaluated a new, relatively simple, non-culture method (MicroTrak, Syva Co., Palo Alto, CA) that requires less than one hour to complete. Two hundred fifty-one cervical and 209 male urethral specimens from three Richmond health clinics were read by direct immunofluorescence staining and compared with cell culture technics using iodine staining. Patient specimens were applied directly onto microscope slides (8 mm well) and stained with a fluorescein-labeled monoclonal antibody. Slides were examined for 10-15 minutes at X1,000 using an AO epifluorescent microscope and were considered positive if five or more typical elementary bodies were seen. The sensitivity, specificity, positive and negative predictive values for the direct smear were 89%, 97%, 85%, and 98% for males, and 93%, 96%, 85%, and 98% for females, respectively. The rapid direct specimen test appears to be a satisfactory method for detecting chlamydia in male and female genital specimens.

The bactericidal activity of clarithromycin versus ampicillin alone and in combination with omeprazole and/or bismuth against clarithromycin-susceptible and clarithromycin-resistant strains of Helicobacter pylori.

We evaluated the in vitro bactericidal effect of clarithromycin versus ampicillin alone and in combination against clarithromycin-sensitive and clarithromycin-resistant strains of Helicobacter pylori. No combination containing clarithromycin achieved complete bactericidal effect against clarithromycin-resistant strains. Complete bactericidal effect was achieved for all strains by triple-agent combinations that contained bismuth, omeprazole, and relatively high concentrations of ampicillin. These in vitro results demonstrate the additive bactericidal activity provided by a combination of agents for the eradication of H. pylori. Bismuth may play a particularly important role in the bactericidal effect.

Listeria monocytogenes keratitis.

We treated a farmer who had Listeria monocytogenes bacterial keratitis. Therapy with topical antibiotics was unsuccessful; it was necessary to treat the patient with topical and systemic penicillin and gentamicin. To elucidate the pathogenesis of this infection, we developed a rabbit model. Using the patient's strain of L. monocytogenes, we determined that the severity of the rabbit infection was dose-related. If we used an inoculum of more than 10(7) organisms, many of the features of the human Listeria keratitis were mimicked. We also found that treatment with either penicillin or gentamicin did not control the infection as well as using both antibiotics simultaneously, a combination which resulted in relatively rapid resolution of infection and no corneal scarring. The human and animal data indicate that L. monocytogenes can be a virulent corneal pathogen. Listeria corneal infections must be treated aggressively with both penicillin and gentamicin to prevent permanent visual loss.

Native valve endocarditis caused by an organism resembling Corynebacterium striatum.

An organism resembling Corynebacterium striatum was isolated from the blood of a patient with acute aortic valvular insufficiency and no history of valvular heart disease. At autopsy, histopathologic examination of the aortic valve revealed pleomorphic gram-positive bacilli and destruction of valvular tissue. Our isolate differed from other nondiphtherial corynebacteria, including the type strain of C. striatum (ATCC 6940), in its ability to reduce nitrite. Nitrite reduction may be useful for distinguishing strains of corynebacteria.

Comparison of rapid urease tests, staining techniques, and growth on different solid media for detection of Campylobacter pylori.

Thirty-nine single antral biopsies (phase 1) and 99 sets of six antral biopsies (phase 2) were collected from 132 patients, and 87 (63%) yielded positive cultures for Campylobacter pylori. Of several primary media tested in phase 1, tryptic soy agar and Skirrow agar, each supplemented with 10% whole sheep blood, supported relatively good growth of C. pylori. In phase 2, four of the six biopsies in each set were tested with different urease systems. Selective urea agar for rapid identification was the most sensitive (39 of 63 [62%] at 1 h) and specific (100%); however, the difference between this system and the CLOtest was not statistically significant. The remaining two biopsies, one transported in saline and the other transported in a supplemented tryptic soy broth, were ground separately and inoculated onto tryptic soy agar and Skirrow agar, each supplemented with 10% whole sheep blood. In selected instances, 10% horse serum or 10% horse serum and 5 mM urea or 1% cholesterol were also added to the media. Smears stained with a modified Gram stain or acridine orange detected 68% of 63 culture-positive biopsies; no false-positive results were reported. Skirrow agar supported better growth of C. pylori than did tryptic soy agar; the nonselective medium was also overgrown with contaminants in 25 to 30% of the positive cultures. Based on colony size, Skirrow agar supplemented with 10% whole sheep blood, 10% horse serum, and 1% cholesterol supported optimal growth of C. pylori. Fresh media supported better growth than did prepoured commercial media (P less than or equal to 0.004). Saline was a convenient and satisfactory transport medium for antral biopsies.

Use of time-kill methodology to assess antimicrobial combinations against metronidazole-susceptible and metronidazole-resistant strains of Helicobacter pylori.

Optimal therapy for Helicobacter pylori infection to date, consists of metronidazole, bismuth, and tetracycline. This combination, however, is less effective against metronidazole-resistant organisms. We used a time-kill kinetic methodology to assess the bactericidal effects of selected agents, alone and in combination, to a metronidazole-susceptible and a metronidazole-resistant strain of H. pylori. single, double, and triple agents showed increasing bactericidal activity. The combination of metronidazole, bismuth, and tetracycline showed maximal killing effect (no detectable regrowth) against the susceptible strain, but against the resistant strain this combination showed less killing. The time-kill methodology may therefore offer an in vitro approach to the initial selection of agents to be evaluated for the treatment of H. pylori infections.

Factors affecting growth and susceptibility testing of Helicobacter pylori in liquid media.

In order to increase the database for in vitro growth and/or susceptibility testing in liquid media, we evaluated the growth of Helicobacter pylori in broth media containing 5% sheep blood. We also compared the effect of bismuth on the growth of H. pylori in broth media containing 10% fetal calf serum with the effect on growth in media containing 0.5% starch. In contrast to the result seen with agar, we found that sheep blood, whether whole or laked, inhibited the growth of H. pylori in broth media. In addition, we found that bismuth inhibited growth in media with starch but that this inhibition was negated in media with serum.

Utilization of time-kill kinetic methodologies for assessing the bactericidal activities of ampicillin and bismuth, alone and in combination, against Helicobacter pylori in stationary and logarithmic growth phases.

Assessment of in vitro susceptibility testing of Helicobacter pylori is difficult because of the fastidious, slowly growing nature of this microorganism. The high rate of relapse observed clinically and a possible subpopulation of cells that are not actively replicating suggest the potential need for bactericidal therapy in order to eradicate H. pylori. We used modified time-kill kinetic methodology in order to evaluate the bactericidal activities of ampicillin and bismuth, alone and in combination, against three strains of H. pylori in both a stationary (slow) growth phase and a logarithmic (rapid) growth phase. We found that ampicillin produced a decrease in CFU per milliliter (2 to 4 log10 units) for three strains of H. pylori when tested in logarithmic growth phases but was less inhibitory (< 1-log10-unit decrease in CFU per milliliter) when tested in a stationary growth phase. In contrast, bismuth, when tested in a logarithmic growth phase, produced little inhibitory effect, as the CFU for all strains tested increased above the inoculum. However, when tested in a stationary growth phase, bismuth produced a decrease in CFU per milliliter of < 1 to > 3 log10 units). The activities of these two agents when combined mimicked the activity of the most active drug alone for that growth phase. We conclude that the clinical use of ampicillin combined with bismuth has been more effective than that of either agent used alone because ampicillin targets replicating cells, whereas bismuth targets cells that are not actively replicating.

In-vitro evaluation of nitrofurantoin as an alternative agent for metronidazole in combination antimicrobial therapy against Helicobacter pylori.

Increasing metronidazole resistance suggests the need for alternative antibiotics for combination therapy of Helicobacter pylori infections. We evaluated a metronidazole-resistant and a clarithromycin-resistant strain of H. pylori under stationary growth phase conditions that favoured physiological conditions in order to determine if nitrofurantoin might be a suitable alternative for metronidazole in combination therapy. The results demonstrated that the triple combination of bismuth, tetracycline and nitrofurantoin achieved greater bactericidal activity against these two strains than did the combination of bismuth, tetracycline and metronidazole. These results suggest that further evaluation is warranted.

Pneumonia and empyema infection associated with a Bacillus species that resembles B. alvei.

An organism resembling Bacillus alvei was isolated from the lung and pleural fluid of an immunocompetent patient. The isolate differed from the type strain of B. alvei in its ability to reduce nitrate and its inability to produce dihydroxyacetone and acetylmethylcarbinol. The isolate was resistant to ciprofloxacin and showed intermediate susceptibility to vancomycin.

Isolation of a beta-lactamase-producing, aminoglycoside-resistant strain of Enterococcus faecium.

Beta-Lactamase-producing, aminoglycoside-resistant strains of Enterococcus faecalis have been isolated from different geographic areas and are endemic at our institution. We report the isolation of a beta-lactamase-producing, aminoglycoside-resistant strain of E. faecium. The beta-lactamase was plasmid mediated and transferable with high frequency into a plasmid-free E. faecalis recipient strain. MICs suggested that the E. faecium strain also contained intrinsic (chromosomal) resistance to penicillins.

In-vitro activity of LY146032 against Staphylococcus aureus and S. epidermidis.

The antibacterial activity of LY146032, a new cyclic polypeptide, was compared with that of vancomycin against 163 isolates of methicillin-susceptible and methicillin-resistant Staphylococcus aureus and S. epidermidis. The MICs of LY146032 and vancomycin for 90% of the isolates were 1.0 mg/l and 2.0-4.0 mg/l, respectively. Interpretative guidelines for 15 micrograms and 30 micrograms LY146032 discs could not be established because all isolates tested were susceptible to LY146032, on the basis of achievable serum levels. With one exception, MBC to MIC ratios of LY146032 and vancomycin were less than or equal to 2. Inoculum size had minimal effect on ratios. In time-kill studies, both drugs were 99.9% bactericidal at 6 h for four isolates at concentrations four times the MBC or less. No change in LY146032 activity was observed between isogenic pairs that were resistant to other antibiotics. Thus, LY146032 was very active in vitro against all staphylococcal isolates.

Occurrence and detection of extended-spectrum beta-lactamases in members of the family Enterobacteriaceae at a veterans medical center: seek and you may find.

A total of 907 consecutive isolates of members of the family Enterobacteriaceae recovered during a 20-week period were tested for production of extended-spectrum beta-lactamases (ESBLs) by the double-disk (DD) potentiation method. Of 84 DD-positive isolates, 83 (9.2%) produced ESBLs based on isoelectric focusing. SHV-derived ESBLs and several TEM-derived ESBLs were present in nine species, including the first isolate of Citrobacter koserii and Morganella morganii known to harbor an SHV-derived ESBL. Results of testing 58 nonrepeat isolates for ESBL production by several recommended methods were as follows (percent detected in parentheses): DD method with aztreonam (95), ceftazidime (79), ceftriaxone (88), or cefpodoxime (90); broth microdilution method with ceftazidime (86) or cefotaxime (91) alone or in combination with clavulanate; and the standard disk diffusion method with new breakpoints and standard concentrations of aztreonam (78), ceftazidime (79), ceftriaxone (83), or cefpodoxime (98) or a novel concentration (5 microg) of ceftazidime (88). In three instances during an extended part of the study, an ESBL-producing isolate and a non-ESBL-producing isolate of the same species were recovered from a single blood culture bottle. These data indicate that ESBLs occur in several species of Enterobacteriaceae and at a relatively high incidence at our institution and that the standard disk diffusion method with cefpodoxime and the DD method with several beta-lactams are practical and cost-effective methods for detecting ESBL-producing isolates of Enterobacteriaceae.

Occurrence and detection of AmpC beta-lactamases among Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis isolates at a veterans medical center.

AmpC beta-lactamases are cephalosporinases that confer resistance to a wide variety of beta-lactam drugs and that may thereby create serious therapeutic problems. Although reported with increasing frequency, the true rate of occurrence of AmpC beta-lactamases in Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis remains unknown. We tested a total of 1,286 consecutive, nonrepeat isolates of these three species and found that, overall, 45 (3.5%) yielded a cefoxitin zone diameter less than 18 mm (screen positive) and that 16 (1.2%) demonstrated AmpC bands by isoelectric focusing. Based on the species, of 683 E. coli, 371 K. pneumoniae, and 232 P. mirabilis isolates tested, 13 (1.9%), 28 (7.6%), and 4 (1.7%), respectively, demonstrated decreased zone diameters and 11 (1.6%), 4 (1.1%), and 1 (0.4%), respectively, demonstrated AmpC bands. Cefoxitin resistance was transferred for all but 8 (E. coli) of the 16 AmpC producers. We also describe a three-dimensional extract test, which was used to detect phenotypically isolates that harbor AmpC beta-lactamase. Of the 45 cefoxitin-resistant isolates, the three-dimensional extract test accurately identified all 16 AmpC producers and 28 of 29 (97%) isolates as non-AmpC producers. Interestingly, most (86%) isolates in the latter group were K. pneumoniae isolates. These data confirm that, at our institution, E. coli, K. pneumoniae, and P. mirabilis harbor plasmid-mediated AmpC enzymes.

Tetrazolium reduction as an aid for streptococcal growth detection with agar dilution susceptibility testing.

A dye reduction method for determining a definitive endpoint with agar dilution susceptibility testing has been developed. Bacterial growth was determined by applying to the inoculum spot a dye solution containing 2-(p-iodophenyl)-3-(p-nitrophenyl)-5-phenyltetrazolium chloride and phenazine methosulfate. Viable colonies reduced the tetrazolium salt to a visible red color within 3 to 5 min. The minimum inhibitory concentrations of six antimicrobial agents tested against 167 clinical streptococcal isolates were recorded before and after the addition of the tetrazolium-phenazine methosulfate solution. A total of 252 discrepancies (25%) were observed, and of these, 30 (12%) differed by more than one tested antibiotic concentration. Endpoint reproducibility of the dye procedure was assessed by four technologists in a double-blind study. A 2.7-fold reduction in disagreement was observed when the dye was used. Use of the tetrazolium-phenazine methosulfate solution involves little deviation from standard antimicrobial susceptibility test procedures and yields more accurate, as well as reproducible, susceptibility results.

Chemical and catalytic properties of the peroxisomal acyl-coenzyme A oxidase from Candida tropicalis.

The peroxisomal acyl-CoA oxidase has been purified from extracts of the yeast Candida tropicalis grown with alkanes as the principal energy source. The enzyme has a molecular weight of 552,000 and a subunit molecular weight of 72,100. Using an experimentally determined molar extinction coefficient for the enzyme-bound flavin, a minimum molecular weight of 146,700 was determined. Based on these data, the oxidase contains eight perhaps identical subunits and four equivalents of FAD. No other beta-oxidation enzyme activities are detected in purified preparations of the oxidase. The oxidase flavin does not react with sulfite to form an N(5) flavin-sulfite complex. Photochemical reduction of the oxidase flavin yields a red semiquinone; however, the yield of semiquinone is strongly pH dependent. The yield of semiquinone is significantly reduced below pH 7.5. The flavin semiquinone can be further reduced to the hydroquinone. The behavior of the oxidase flavin during photoreduction and its reactivity toward sulfite are interpreted to reflect the interaction in the N(1)-C(2)O region of the flavin with a group on the protein which acts as a hydrogen-bond acceptor. Like the acyl-CoA dehydrogenases which catalyze the same transformation of acyl-CoA substrates, the oxidase is inactivated by the acetylenic substrate analog, 3-octynoyl-CoA, which acts as an active site-directed inhibitor.

Two similar but atypical strains of coryneform group A-4 isolated from patients with endophthalmitis.

Corynebacterium species and other coryneform organisms isolated from clinical specimens are frequently considered contaminants. We isolated two strains of a gram-positive organism from the vitreous fluid of two patients with endophthalmitis who had previously received intraocular lens transplants. The biochemical characteristics and gas chromatographic patterns of both isolates were similar to those of coryneform group A-4 strains. Major differences included esculin hydrolysis, nitrate reduction, growth pigment, and lactic acid production. These two strains along with a limited number of strains collected at the Special Bacterial Pathogens Laboratory (Division of Bacterial Diseases, Centers for Disease Control, Atlanta, Ga.) may represent a subgroup of coryneform group A-4. Results of in vitro susceptibility testing performed with antimicrobial agents commonly used to treat patients with bacterial endophthalmitis underscore the importance of determining MBCs for slow-growing organisms. This report cautions microbiologists not to discard organisms frequently considered contaminants when isolated from body fluids that are normally sterile and from patients receiving local steroids.