Treatment of central nervous system fungal infection with ketoconazole.

Two patients with fungal infection of the central nervous system (coccidioidal meningitis and cerebral histoplasmomas) were treated with ketoconazole for 30 months. Both responded to dosages substantially less than those described previously for similar infections. Neither patient experienced any significant adverse effects from the prolonged therapy.

Optimal cefotaxime dosing for gram-negative bacteremia: effective trough serum bactericidal titers and drug concentrations 8 and 12 hr after 1- or 2-gm infusions.

Thirteen adult patients (47-81 yr) with gram-negative bacteremia and normal (less than or equal to 1.5 mg/dl) serum creatinines were treated with 1 or 2 gm of cefotaxime every 8 or 12 hr. The infecting organisms were Escherichia coli (9 strains), Klebsiella pneumoniae (2 strains), and one isolate of Salmonella enteritidis and Serratia marcescens. All patients recovered without any serious sequelae. The range of MICs for cefotaxime and desacetyl-cefotaxime were 0.015-0.25 micrograms/ml and 0.015-4.0 micrograms/ml, respectively. The MBC values for cefotaxime and desacetyl-cefotaxime were identical to the MIC values except for two strains. The trough levels of cefotaxime varied from 65.9 to 1.1 micrograms/ml. The serum concentration of desacetyl-cefotaxime varied from 84 to less than 1.0 microgram/ml. All corresponding trough serum inhibitory activities (SIA) were greater than or equal to 1:32. Comparisons of calculated and directly measured serum bactericidal activity (SBA) and SIA results suggest an additive and occasional synergistic benefit of the cefotaxime desacetyl metabolite. This study supports the clinical efficacy and cost-effectiveness of 8- and 12-hr dosing intervals for cefotaxime against bacteremic gram-negative strains having the usual high susceptibility (MICs, less than or equal to 0.25 micrograms/ml) to the newer cephalosporins.

Postinfectious encephalopathy in a child following Campylobacter jejuni enteritis.

We report a case of acute postinfectious encephalopathy in a child following Campylobacter jejuni enteritis. Serial MR scans showed lesions involving predominantly gray matter and the adjacent subcortical white matter--findings different from those in other immune-mediated disorders, such as systemic lupus erythematosus, in which either white or gray matter may be involved, and acute disseminated encephalomyelitis, in which white matter abnormalities predominate with involvement of the subcortical white matter.

A prospective study of tracheobronchial bacterial flora in acutely brain-injured patients with and without antibiotic prophylaxis.

The authors observed prospectively 28 brain-injured patients, who required respiratory tract intubation, to determine the effect of antibiotic prophylaxis on bacterial flora, the rate of flora change, and the appearance of infection. Antibiotics not only failed to alter the rate of abnormal colonization but were associated with an earlier appearance of Gram-negative bacilli, the organisms that produced the most severe infections. Although more infections occurred in patients initially untreated with antibiotics, these infections were usually mild and caused by organisms susceptible to highly effective and relatively safe drugs. Although highly reproducible as a laboratory determination, the nitroblue tetrazolium dye test score showed no consistent relationship with the presence or absence of bacterial infection. Regular and extensive clinical and laboratory observations, including cultures of the respiratory tract helped to make the antibiotic administration in these patients specific, appropriate, and reasonable. Broad spectrum antibiotic prophylaxis does not prevent and may enhance the development of severe pulmonary infection in these patients.

Alternaria osteomyelitis. Evidence of specific immunologic tolerance.

A 31-year-old man had a maxillary sinus infection and osteomyelitis. In vitro lymphocyte transformation studies indicated that he had a specific immune tolerance to Alternaria organisms. The etiologic agent was recovered and was identified as Alternaria alternata.

Fungemia caused by an amphotericin B-resistant isolate of Sporothrix schenckii. Successful treatment with itraconazole.

A 58-year-old, alcoholic, diabetic man presented with multiple, ulcerated skin lesions and polymicrobial septicemia. Sporothrix schenckii was recovered from blood cultures and was resistant to amphotericin B by in vitro testing. Amphotericin B therapy failed, but the patient responded dramatically to itraconazole therapy, only to relapse 3 months after therapy was stopped. Reinstitution of itraconazole therapy has produced another dramatic response. This report is noteworthy for three reasons. First, to our knowledge, it represents only the second reported instance of fungemia with S schenckii that responded to medical therapy. Second, it illustrates that in vitro antifungal susceptibility tests may predict clinical infection response to drug therapy. Third, it suggests that itraconazole has significant promise in treating systemic sporotrichosis.

Toxic shock syndrome following breast and nasal surgery.

Toxic shock syndrome is a rapidly developing disease which may be lethal if not recognized and treated early. While this disease is usually associated with menstruating females, it is being seen in both male and female patients following clean, elective surgery. Toxic shock syndrome has been reported following surgical procedures which normally have a very low incidence of postoperative wound infections. Toxic shock syndrome is associated with Staphylococcus aureus bacteria which produce the toxic shock syndrome toxin 1. Three patients with postoperative toxic shock syndrome, of varying degrees of severity, are presented. Prompt institution of resuscitative and therapeutic measures can prevent the potentially fatal outcome of this postoperative complication.

Antiviral drug therapy.

Major advances in molecular virology have led to the development of new antiviral compounds. These drugs include ribavirin, used in the treatment of severe respiratory syncytial virus infection in children; amantadine, used in the prophylaxis and treatment of influenza A infection; acyclovir, used in a variety of herpesvirus infections, including primary gingivostomatitis, genital herpes and herpes zoster; ganciclovir, used in the treatment of retinitis due to cytomegalovirus, and zidovudine, used in the prophylaxis and treatment of human immunodeficiency virus infection.

Evaluation of H2O2 prophylaxis of bacteriuria in patients with long-term indwelling Foley catheters: a randomized controlled study.

Since the long-term catheterized patient is at significant risk of urinary tract infection, and the catheter drainage bags of these patients are at significant risk of becoming reservoirs for nosocomial pathogens, we carried out a randomized, controlled study to determine the efficacy of intermittent drainage bag instillation of hydrogen peroxide (H2O2) in patients requiring indwelling Foley catheters for 5 days or more. Herein we report the effects of this technique on the rates of catheter and bag bacteriuria, the duration to positive culture, the temporal relationships observed, and the spectrum of organisms recovered. Bag source bacteriuria was found with the same frequency in both control and H2O2 groups. H2O2 did reduce contamination of the drainage bag but did not reduce catheter-associated bacteriuria or frequency of symptomatic urinary tract infection. Furthermore, H2O2 did not reduce the frequency of bag contamination with most of the common nosocomial urinary pathogens.

Toxic shock syndrome in menstruating women.

Eight adult women became severely ill with an acute, toxic erythroderma during menses. The syndrome was characterized by fever, generalized erythema, profound shock, multiple organ dysfunction, and desquamation occurring several days after the rash had faded. Gastrointestinal and cardiovascular abnormalities were present in all patients; three patients required ventilatory support; dialysis was performed on two; and one patient died. Mild relapse occurred in two patients during subsequent menses; the other patients have recovered without sequelae during follow-up of 6 to 42 months. Cervical colonization or local infection with Staphylococcus aureus is associated with this syndrome.

Wound botulism in a patient with a tooth abscess: case report and review.

We describe a case of wound botulism associated with a tooth abscess in a 5-year-old boy. We reviewed the literature and reports to the Centers for Disease Control and Prevention (Atlanta) of laboratory-confirmed cases of wound botulism. From 1943 through 1990, 47 cases were reported. Type A botulinus toxin was identified in 32 cases, type B in 13, types A and B in 1, and an unknown type in 1. Botulism was associated with wounds from trauma, use of injectable drugs, and surgery. Sinusitis after use of intranasal cocaine has also been associated with botulism. Treatment for wound botulism includes prompt debridement of the wound for eliminating anaerobic conditions, intensive care, and treatment with antitoxin.

Colorado tick fever: clinical, epidemiologic, and laboratory aspects of 228 cases in Colorado in 1973-1974.

During 1973 and 1974, we looked for cases of Colorado tick fever throughout Colorado; 228 cases were identified. Although 90% of the patients reported exposure to ticks before illness, only 52% were aware of an actual tick bite. Typical symptoms of fever, myalgia, and headache were common, but gastrointestinal symptoms were also prominent in 20% of the patients. Twenty percent were hospitalized; no deaths or permanent sequelae were noted. Persistent viremia (greater than or equal to 4 weeks) was found in about half of the cases; this finding was not associated with the occurrence of prolonged symptoms (greater than or equal to 3 weeks), which were also reported in half of the cases. One patient became reinfected with the virus. Increasing tourism in endemic areas and the frequent occurrence of prolonged or biphasic illnesses provide the potential for patients with Colorado tick fever to seek medical care anywhere in the United States.

Nosocomial fungemia in neonates associated with intravascular pressure-monitoring devices.

In the period from January, 1982, to March, 1983, eight infants in the neonatal intensive care unit at one hospital had blood cultures positive for Candida parapsilosis; six cases had occurred after December, 1982. Epidemiologic investigation included a case-control study comparing the 8 cases with 29 birth weight-matched controls. Logistic regression analysis indicated that the model that best fit the observed data included the following risk factors for fungemia: duration of umbilical artery catheterization; duration of receipt of parenteral nutrition; and estimated gestational age. Parenteral nutrition therapy was often administered through the umbilical artery catheters, which were also used for monitoring arterial pressure; transducer domes thus contained parenteral nutrition fluid. Transducers were usually disinfected with alcohol. Laboratory investigation showed that the heads of 6 of 11 in-use blood pressure transducers and 1 of 4 transducers in storage after cleaning were culture-positive for C. parapsilosis. After control measures were instituted no further cases occurred.