Bennett Lorber

Gastroenteritis Due to Listeria monocytogenes

It has been known for a long time that many patients experience diarrhea antecedent to the development of bacteremia or meningoencephalitis due to Listeria monocytogenes, but it was only recently that convincing evidence was obtained that this organism can cause acute, self-limited, febrile gastroenteritis in healthy persons. At least 7 outbreaks of foodborne gastroenteritis due to L. monocytogenes have been reported. Illness typically occurs 24 h after ingestion of a large inoculum of bacteria and usually lasts 2 days. Common symptoms include fever, watery diarrhea, nausea, headache, and pains in joints and muscles. L. monocytogenes should be considered to be a possible etiology in outbreaks of febrile gastroenteritis when routine cultures fail to yield a pathogen.

Clindamycin Compared with Penicillin for the Treatment of Anaerobic Lung Abscess

The clinical efficacy of clindamycin was compared with that of penicillin in a randomized study of the treatment of community-acquired putrid lung abscess. After starting therapy, patients treated with clindamycin had a shorter febrile period and fewer days of fetid sputum than patients treated with penicillin (mean 4.4 versus 7.6 days and 4.2 versus 8.0 days, respectively, p less than 0.05). Four of 20 patients treated with penicillin had clinically significant pulmonary or pleural extension of their infection within 10 days after starting therapy; this was not found in any of 19 patients treated with clindamycin (p less than 0.05). Penicillin treatment failed in two additional patients after 20 days of therapy. Within 1 month after treatment, 1 of 4 patients given penicillin for 3 weeks had relapse, but none of the 13 patients given clindamycin for 3 or 6 weeks, and none of the 5 patients given penicillin for 6 weeks had relapse. Overall, only 8 of 15 patients treated with penicillin who could be followed to the end of the study were cured, whereas all 13 patients treated with clindamycin who could be followed were cured (p less than 0.01). These results suggest that penicillin may not be optimal therapy for anaerobic lung abscess.

The bacteriology of intra-abdominal infections.

Intra-abdominal infections are commonly closed space infections, and the primary mode of therapy is surgical drainage and removal of necrotic tissue. However, the importance of appropriate antimicrobial therapy is not to be underemphasized.

Anterior sacral meningocele: Report of five cases and review of the literature

SummaryFive new cases of anterior sacral meningocele are presented, including one secondary to neurofibromatosis, a previously undescribed association. The literature is reviewed, drawing attention to the relationship between anterior sacral meningocele, sacral dysgenesis, and other congenital anomalies. Special consideration is given to the clinical features of this entity, as well as to the techniques and results of surgical management.

Antipyretic orders in a university hospital

PURPOSE Antipyretics are prescribed for many hospitalized patients, but details concerning prescribing practices are not known. This study was designed to determine the incidence and format of antipyretic orders in a university-based tertiary-care center, and to ascertain whether orders are correlated with patient characteristics or hospital services. PATIENTS AND METHODS The records of 300 randomly selected patients on the medicine, general surgery, neurosurgery, and obstetrics and gynecology services, and of 75 patients admitted with pneumonia and fever were retrospectively reviewed using a standardized data form. RESULTS Orders for acetaminophen prn (as needed), without further explanation, were interpreted by the nursing staff as antipyretic orders; 78% of patients with such an order and fever received acetaminophen during the febrile episode. If orders of this type were included, 153 (51%) of the randomly selected patients received an antipyretic order. Gender, age, duration of hospitalization, intensive care unit residence, fever, and presence of a condition worsened by fever were not significant independent predictors of antipyretic prescription, but documented infection and hospitalization on the medicine and neurosurgery services were, with adjusted odds ratios of 2.5 (95% confidence interval [CI] 1.3 to 5.0), 9.4 (95% CI 3.6 to 25), and 14 (95% CI 5.0 to 41), respectively. Of patients who received an antipyretic order, 70% had an admission order for antipyretics; 26%, an order prompted by fever; and 79%, an order while afebrile. In 86%, the order was written prn without further explanation. Around-the-clock dosing, automatic stop orders, and acknowledgement and justification of orders were rare. CONCLUSION Antipyretic orders are routine and correlate more strongly with hospital service than with individual patient characteristics. They are umprecisely written and generally leave decisions about antipyretic administration to the complete discretion of the nursing staff.

Successful treatment of methicillin-resistant Staphylococcus aureus endocarditis with telavancin

Sir, Within our institution, we have recently seen an increase in bloodstream infections due to methicillin-resistant Staphylococcus aureus (MRSA) having decreased responsiveness to glycopeptides. Testing has revealed that these isolates are neither vancomycin intermediate nor heterogeneous vancomycin intermediate. Patients continue to be bacteraemic despite therapeutic levels of vancomycin. In September 2009, the FDA approved telavancin for the treatment of complicated skin and soft-tissue infections. To date, there have been no reports of the use of telavancin in bacteraemic patients. Here we report the successful use of telavancin for MRSA bacteraemia and right-sided endocarditis. A patient with a history of hepatitis C and intravenous drug use presented with fevers and chills. Blood cultures grew MRSA (vancomycin MIC≤0.5 mg/L, daptomycin MIC≤1 mg/L) and he was begun on 15 mg/kg vancomycin every 12 h. He was found to have septic pulmonary emboli and a pleural effusion. A transoesophageal echocardiogram showed severe tricuspid valve regurgitation with a large tricuspid valve vegetation. Blood cultures remained positive through 8 days of vancomycin treatment with documented trough levels of 15–20 mg/L. Treatment was changed to 10 mg/kg telavancin intravenously every 24 h. Blood cultures became negative within 1 day of the start of telavancin. The patient’s creatinine was monitored and remained stable from admission. The patient underwent a tricuspid valve repair for severe tricuspid regurgitation 1 month after his initial positive culture. He completed 4 weeks of telavancin and was discharged home in a stable condition 6 weeks after his admission. At follow-up 6 weeks after completing treatment, the patient was afebrile with documented negative blood cultures. To our knowledge, this is the first case of persistent MRSA bacteraemia treated successfully with telavancin. Telavancin is a lipoglycopeptide with a mechanism of action similar to that of the glycopeptides but with an added mechanism that interferes with cell membrane function. It is reportedly rapidly bactericidal against S. aureus, thus having potential for use in bacteraemic patients. The study of telavancin in MRSA bacteraemia has been completed in murine models with the comparator being vancomycin. In this model, telavancin demonstrated greater killing activity than vancomycin, and a statistically significant difference in survival was found between the two groups with 0% survival for vancomycin and 93% for telavancin. These results have been attributed to the dual mechanism of action of telavancin as well as a longer post-antibiotic effect. With the increasing frequency of persistent MRSA bacteraemia with decreased responsiveness to vancomycin and failures reported with daptomycin after vancomycin use, new therapeutic options are desirable. Clinical studies will be necessary to determine whether telavancin offers advantages over other currently available antibiotics.

Esophageal Bacteria and Barrett's Esophagus: A Preliminary Report

The objective of this study was to investigate if esophageal bacteria are associated with Barretts esophagus (BE). This study was comprised of a retrospective (Part 1) and a subsequent prospective (Part 2) study. In Part 1, Gram stains were performed on esophageal biopsy specimens obtained in 47 patients. Bacteria were quantitated from 0 to 4. In Part II, Gram stains and cultured bacterial counts of esophageal biopsies were obtained in 18 GERD patients (9 with BE and 9 without BE). Part 1 results were as follows. Bacteria were found in 37 of 47 esophageal biopsies. Quantitative bacterial stain scores for BE (2.5±0.2) were higher than for non-BE (1.5±0.3; P = 0.02). The quantitative bacterial stain scores correlated with increasing severity of dysplasia (r = 0.37, P = 0.028). In Part 2, bacteria were found in 8 of 18 esophageal biopsies by Gram stain (6 of 9 patients with BE vs. 2 of 9 non-BE). The distal esophageal bacterial stain scores in BE patients (1.6±0.5) were higher than in those without BE (0.4±0.3; P = 0.07). Patients on proton pump inhibitors tended to have higher bacterial stain scores (1.2±0.4) than patients who were not (0.7±0.3; P = 0.45). Bacterial colony counts were similar in patients with BE compared to those without BE. In conclusion, bacteria in esophageal biopsies were detected more often in BE than non-BE. Increasing bacterial stain scores were associated with metaplasia and increasing dysplasia. Esophageal bacteria, possibly related to stasis or gastric acid suppression therapy, may play a role in the pathogenesis of BE and dysplasia.

Changing patterns of infectious diseases.

In the 20 years that have passed since I received my medical degree, some of the most evident, striking, and interesting changes in patterns of diseases have occurred among those due to transmissible agents. Among other changes are the recognition of new diseases, new clinical manifestations for old diseases, new ecologic niches for traditional pathogens, and new modes of disease transmission. Implicated causes for these changes include alterations in lifestyle such as sexual behaviour, leisure activity, and dietary trends, along with the impact of immigration and the effects of medical progress. A review of these changing patterns demonstrates the dynamic nature of medicine and suggests lessons for medical education.

Listeria Meningitis During Cefazolin Therapy

Excerpt Suboptimal response of meningitis to cephalothin therapy (1-2) and actual development of meningitis during cephalothin therapy (3) have been reported. We recently observed a patient who dev...

Rapid assay for determination of trimethoprim and sulfamethoxazole levels in serum by spectrofluorometry.

A rapid spectrofluorometric method for determining the levels of both trimethoprim and sulfamethoxazole from the same specimen of serum is described. The method involves stepwise extraction of the specimen first with chloroform at an alkaline pH (pH 9.0) for trimethoprim followed by n-butyl chloride at an acidic pH (pH 2.0) for sulfamethoxazole. To quantitate trimethoprim, the chloroform layer was subjected to fluorometry by exciting the specimen at 295 nm and measuring the relative intensity at 330 nm. To determine sulfamethoxazole levels, the n-butyl chloride layer was subjected to fluorometry by exciting the specimen at 285 nm and measuring the relative intensity at 330 nm. Relative intensities were linear (r greater than 0.99) over the concentration ranges of 0.5 to 40 microgram/ml for trimethoprim and 1 to 400 microgram/ml for sulfamethoxazole. Values obtained by this spectrofluorometric procedure were in excellent agreement with those obtained by a conventional fluorometric assay for trimethoprim and a colorimetric assay for sulfamethoxazole. Elevated levels of endogenous metabolic products and numerous other drugs, including a number of antimicrobial agents, did not interfere with the method. Although salicylates interfere with the determination of sulfamethoxazole, an appropriate correction can be made. This method can also be used to determine the drug levels in cerebrospinal fluid.