C. Brandimarte

Diuretic therapy in heart failure: Current controversies and new approaches for fluid removal

Hospitalization for heart failure is a major health problem with high in-hospital and postdischarge mortality and morbidity. Non-potassium-sparing diuretics (NPSDs) still remain the cornerstone of therapy for fluid management in heart failure despite the lack of large randomized trials evaluating their safety and optimal dosing regimens in both the acute and chronic setting. Recent retrospective data suggest increased mortality and re-hospitalization rates in a wide spectrum of heart failure patients receiving NPSDs, particularly at high doses. Electrolyte abnormalities, hypotension, activation of neurohormones, and worsening renal function may all be responsible for the observed poor outcomes. Although NPSD will continue to be important agents to promptly resolve signs and symptoms of heart failure, alternative therapies such as vasopressine antagonists and adenosine blocking agents or techniques like veno-venous ultrafiltration have been developed in an effort to reduce NPSD exposure and minimize their side effects. Until other new agents become available, it is probably prudent to combine NPSD with aldosterone blocking agents that are known to improve outcomes.

Erysopelothrix rhusiopathiae endocarditis

A case ofErysipelothrix rhusiopathiae endocarditis involving the aortic and mitral valves in a 70-year-old male farmer is reported. The onset of infection was insidious, with a five-month history of low grade fever, malaise and a 20 kg weight loss. The patient eventually developed severe heart failure requiring surgery and died postoperatively ofPseudomonas aeruginosa pneumonia. In vitro studies showed the isolate to be highly susceptible to penicillin, ciprofloxacin and ofloxacin, and resistant to vancomycin.

High rate of oxacillin-resistant Staphylococcus aureus isolates in an Italian University Hospital.

We reviewed our routine clinical laboratory records from January 1990 to March 1993 to evaluate the rate of oxacillin-resistance among nosocomial isolates of Staphylococcus aureus. Of 265 clinically significant isolates, 174 (65%) were oxacillin-resistant S. aureus (ORSA). Most of these strains were obtained from surgery patients and/or were isolated from surgical wounds. The isolations of S. aureus increased during the study period: 45 in 1990, 50 in 1991, 130 in 1992 and 40 in the first trimester of 1993. The annual rates of ORSA among S. aureus isolated varied from 62 to 68% through these years. Most ORSA isolates proved resistant to ciprofloxacin, gentamicin and rifampicin, and susceptible to vancomycin, netilmicin and cotrimoxazole. Based on these results, the need for a stringent application of infection control measures is outlined.

Occurrence of influenza A(H1N1)v infection and concomitant invasive pulmonary aspergillosis in a patient with chronic obstructive pulmonary disease

Paolo Carfagna, Filippo Brandimarte, Roberta Caccese, Domenico Campagna, Camillo Brandimarte and Mario Venditti Department of Internal Medicine, San Giovanni-Addolorata Hospital, Rome, Italy, Department of Emergency Medicine, San Giovanni-Addolorata Hospital, Rome, Italy, Department of Anesthesiology, San Giovanni-Addolorata Hospital, Rome, Italy, Department of Pathology, San Giovanni-Addolorata Hospital, Rome, Italy and Department of Infectious Diseases, Sapienza University, Rome, Italy

Potential of clindamycin in addition to vancomycin for the treatment of oxacillin-resistant Staphylococcus aureus septicemia persisting under vancomycin therapy

We observed seven patients with persistent fever and staphylococcemia under vancomycin-containing antimicrobial regimens who promptly improved as clindamycin was added to the initial antibiotics. Moreover, in all these patients a striking increase in peak and trough serum inhibitory activity (SIR) and serum bactericidal activity (SBA) levels was observed after addition of clindamycin. SIA and SBA levels after administration of a single dose of vancomycin (500 mg), clindamycin (600 mg) or vancomycin + clindamycin were also measured in three healthy volunteers against six ORSA isolates. Unsatisfactory peak SBA levels (0% of cases 1:8) were obtained after vancomycin administration. Vice versa, peak SBA levels 1:8 were obtained in 94% of the cases after clindamycin and in 100% of cases after vancomycin + clindamycin. Time-kill studies showed a borderline or incomplete bactericidal activity of vancomycin against three ORSA isolates from infections that manifested poor or slow response to vancomycin therapy. The combination with clindamycin did not result in a synergistic interaction between the two drugs. It is concluded that addition of clindamycin may be useful in some cases of ORSA septicemia that show poor or slow response to vancomycin therapy. The recommendation for a wider use of this combination of antibiotics requires further documentation of efficacy.

Alterations of coagulase-negative staphylococcal flora in cardiac surgery patients: comparative study between cefamandole and pefloxacin perioperative prophylaxis.

The changes in coagulase-negative staphylococcal flora induced by cefamandole prophylaxis were compared with those induced by pefloxacin prophylaxis among patients undergoing heart valve surgery. Twenty-five patients (15 receiving cefamandole prophylaxis and 10 receiving pefloxacin prophylaxis) were included in the study. In the pefloxacin group, colonization rates in anterior nares and in chest skin or wound that were 60% and 50% respectively before surgery, became 50% and 20% respectively after surgery. In the cefamandole group, colonization rates in anterior nares and chest skin or wound were 53.3% and 60% respectively before surgery and became 53.3% and 40% respectively after surgery. Cefamandole did not appear to induce the emergence of oxacillin or pefloxacin resistant coagulase-negative staphylococcal colonization in any cultured site. On the other hand pefloxacin appeared somewhat more efficacious than cefamandole in eradicating staphylococcal flora of anterior nares and chest skin or wound. Pefloxacin and oxacillin resistant strains were found in the perianal area in 0% of patients before pefloxacin prophylaxis and in 70% of patients after pefloxacin prophylaxis. However, further studies are necessary to confirm the emergence of antibiotic resistant coagulase-negative staphylococci in the intestinal microflora after quinolone administration. The clinical implications of such apparently disturbing phenomenon remain to be evaluated.

STAPHYLOCOCCUS AUREUS MEININGITIS IN NEUROSURGERY ADULT PATIENTS: RETROSPECTIVE CLINICAL AND MICROBIOLOGIC ANALYSIS

We reviewed 12 cases of Staphylococcus aureus meningitis occurring over a 5-year period in five neurosurgery divisions at the Policlinico Umberto I. Six patients had an intraventricular shunt, five had craniotomy, and one had spinal surgery. All patients had one or more underlying causes other than surgery that might have predisposed to infection. Clinical presentation and cerebrospinal fluid (CSF) laboratory findings did not distinguish this form of meningitis from other acute bacterial meningitides. Gram stain of centrifuged CSF showed gram-positive cocci in 83% of cases. Blood cultures were positive in 25% of cases. Overall mortality was 50%. Eight CSF isolates were simultaneously resistant to oxacillin and rifampicin. Six of 10 patients treated with a glycopeptide were cured or improved. The remaining two patients with an oxacillin-susceptible S. aureus infection were cured: one was treated with cefamandole, the other one with ciprofloxacin and rifampicin.

Intravenous ciprofloxacin for the treatment of severe infections.

Intravenous ciprofloxacin at a daily dosage of 400 mg divided in two doses was administered to 19 patients with severe infections caused by ciprofloxacin-susceptible bacteria. These infections included: 11 surgical would infections, 5 soft tissue infections, 2 respiratory tract infections, 1 urinary tract infection. The offending pathogens were: 8 coagulase-negative staphylococci, 3 Staphylococcus aureus, 3 Pseudomonas aeruginosa, 2 Proteus spp., 1 Escherichia coli, 1 Branhamella catarrhalis, 1 Klebsiella ozenae and 1 Serratia liquefaciens. Overall, 17 of 19 infections (89%) showed a satisfactory clinical response to trial therapy (15 cures and 2 improvements). Microbiological eradication was observed in 17 out of 20 isolated pathogens. Emergence of resistance to ciprofloxacin occurred in 1 coagulase-negative Staphylococcus and was associated with clinical failure. No side effects were observed. We conclude that intravenous ciprofloxacin may represent efficacious and safe therapy of severe infections; however close microbiological monitoring seems to be necessary to evaluate the emergence of resistance during quinolone therapy.