Conrad J. Wilkowske

Treatment of Streptomycin-Susceptible and Streptomycin-Resistant Enterococcal Endocarditis

Fifty-six patients with enterococcal endocarditis received 4 weeks of antimicrobial therapy with penicillin G and streptomycin (36 patients) or, if infections were streptomycin resistant, penicillin and gentamicin (20 patients). Compared with patients who had symptoms for less than 3 months, patients with symptoms for more than 3 months had a higher relapse rate (0% versus 44%; p less than 0.001) and mortality (2.5% versus 25%; p less than 0.001). Patients with mitral valve endocarditis had a significantly higher relapse rate (25%) than patients with aortic valve infections (0%) (p less than 0.01). Gentamicin-associated nephrotoxicity was more frequent (p less than 0.001) among patients treated with greater than 3 mg/kg d of gentamicin than among those treated with 3 mg or less (100% versus 20%). Relapse and mortality rates did not differ significantly between patients treated with low-dose or high-dose gentamicin regimens. Patients who have had symptoms of enterococcal endocarditis for more than 3 months or patients with mitral valve infection should receive at least 6 weeks of antimicrobial therapy, but patients without these high-risk factors can be treated for 4 weeks.

Efficacy Of Ganciclovir In Liver And Kidney Transplant Recipients With Severe Cytomegalovirus Infection

Twelve liver and 5 kidney transplant recipients with severe cytomegalovirus infection were treated with Ganciclovir (7.5 mg/kg/day, intravenously). Ten were evaluable (compatible clinical picture, organ involvement shown histopathologically or by culture, viremia, and absence of concomitant infection). All 17 patients were studied for adverse drug side effects. A total of 9 evaluable patients survived the infection; 1 died during treatment due to infection or drug toxicity. A death 19 days after completion of treatment was due to unrelated causes. Patients became afebrile after 2-9 days (mean, 5.3 days) of treatment. Liver function improved, pulmonary infiltrates cleared, and hypoxemia reversed during therapy. Viremia ceased during therapy in 9 patients; asymptomatic viruria persisted or recurred in 6 of 7 patients studied. No relapses occurred during follow-up (7-17 months; mean, 13 months). Transient neutropenia and thrombocytopenia occurred in 3 and 1 patients, respectively. Ganciclovir appears promising for treatment of severe CMV infection in patients with kidney or liver transplants.

Streptococcus mutans endocarditis.

Abstract Nine patients withStreptococcus mutansendocarditis were seen between 1966 and 1973. They had the typical clinical picture of subacute bacterial endocarditis, with fever, heart murmur, and ...

Prophylactic Use of Antimicrobial Agents in Adult Patients

Prophylactic antimicrobial agents are recommended for prevention of a variety of conditions, including tuberculosis, endocarditis, rheumatic fever, recurrent cellulitis and lymphangitis in patients with lymphedema, meningococcal meningitis, bite wounds, and herpes virus infections. In addition, prophylactic antimicrobial agents have proved effective in certain surgical procedures such as a variety of abdominal operations, hysterectomy, and head and neck operations for cancer. Except for oral bowel preparations, administration of antimicrobial agents for prophylaxis should be limited, in general, to the perioperative time period. Doses given more than an hour before or 3 hours after a surgical procedure have not been shown to increase effectiveness, and such an approach increases the cost and the probability of toxicity and superinfection. Investigation of antimicrobial prophylaxis necessitates adequate evaluation of potential advantages and disadvantages in prospective double-blind fashion.

Empiric Therapy With Moxalactam Alone in Patients With Bacteremia

Moxalactam was administered (20 mg/kg intravenously every 8 hours) as single-drug empiric antimicrobial therapy to 63 patients with bacteremia who were neither neutropenic nor immunosuppressed. Six patients (10%) had microorganisms that were susceptible to moxalactam and resistant to all other antimicrobial agents tested; two patients (3%) had microorganisms that were resistant to moxalactam and other agents tested. Of these 63 patients, 47 (75%) were cured with moxalactam therapy. Nine patients (14%) had breakthrough bacteremia while receiving other antimicrobial therapy and were cured subsequently with moxalactam therapy alone. The two major risk factors for failure of moxalactam therapy were polymicrobial bacteremia and an extrahepatic intra-abdominal source of infection; these two conditions frequently coexisted. Six of nine patients with polymicrobial bacteremia died. Superinfection (one pseudomonal, five enterococcal) was responsible for 6 of the 16 treatment failures. Enterococcal superinfection occurred exclusively among patients who had received relatively prolonged therapy with moxalactam for extrahepatic intra-abdominal infection, especially intraabdominal abscess. These five patients died, and postmortem examination showed that enterococcal superinfection was the major cause of death in all. Mild, reversible adverse reactions associated with use of moxalactam occurred in 14 of the 63 patients (22%). None had clinically overt bleeding. The use of moxalactam alone seems to be safe and effective and a cost-effective alternative empiric antimicrobial therapy for most patients with bacteremia who are not immunosuppressed or neutropenic and who are not at high risk of having Pseudomonas or polymicrobial bacteremia.

Bactericidal Activity of Combinations of Gentamicin with Penicillin or Clindamycin Against Streptococcus mutans

Data derived from testing the bactericidal activity of combinations of penicillin with gentamicin or streptomycin and of clindamycin with gentamicin on nine isolates of Streptococcus mutans were analyzed by preparing isobolograms to determine the presence of additive, synergistic, or antagonistic effects. Synergy with penicillin-aminoglycoside combinations was found in two strains; additive effects occurred in seven instances with penicillin-gentamicin combinations; and antagonism occurred in eight instances with clindamycin-gentamicin combinations.