John R. Ebright

Bacterial Pneumonia in the Elderly

A retrospective study was made of patients having community‐acquired pneumonia and treated at a large municipal hospital in 1973. Patients from nursing homes or other paramedical facilities were excluded. The incidence of Gram‐negative bacillary pneumonia was significantly higher in elderly patients compared to two younger groups, and mortality from this type of pneumonia was higher than from pneumococcal or staphylococcal types or from pneumonia of unknown cause. Recommendations are made for the initial treatment of elderly patients with community‐acquired pneumonia.

Antimicrobial Salvage Therapy for Persistent Staphylococcal Bacteremia Using Daptomycin Plus Ceftaroline

PURPOSE Guidelines recommend daptomycin combination therapy as an option for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia after vancomycin failure. Recent data suggest that combining daptomycin with a β-lactam may have unique benefits; however, there are very limited clinical data regarding the use of ceftaroline with daptomycin. METHODS All 26 cases from the 10 medical centers in which ceftaroline plus daptomycin was used for treatment of documented refractory staphylococcal bacteremia from March 2011 to November 2012 were included. In vitro (synergy studies, binding assays, cathelicidin LL-37 killing assays), and in vivo (virulence assays using a murine subcutaneous infection model) studies examining the effects of ceftaroline with daptomycin were also performed. FINDINGS Daptomycin plus ceftaroline was used in 26 cases of staphylococcal bacteremia (20 MRSA, 2 vancomycin-intermediate S aureus, 2 methicillin-susceptible S aureus [MSSA], 2 methicillin-resistant S epidermidis). Bacteremia persisted for a median of 10 days (range, 3-23 days) on previous antimicrobial therapy. After daptomycin plus ceftaroline was started, the median time to bacteremia clearance was 2 days (range, 1-6 days). In vitro studies showed ceftaroline synergy against MRSA and enhanced MRSA killing by cathelicidin LL-37 and neutrophils. Ceftaroline also induced daptomycin binding in MSSA and MRSA to a comparable degree as nafcillin. MRSA grown in subinhibitory concentrations of ceftaroline showed attenuated virulence in a murine subcutaneous infection model. IMPLICATIONS Ceftaroline plus daptomycin may be an option to hasten clearance of refractory staphylococcal bacteremia. Ceftaroline offers dual benefit via synergy with both daptomycin and sensitization to innate host defense peptide cathelicidin LL37, which could attenuate virulence of the pathogen.

Emerging infectious diseases in Mongolia.

Since 1990, Mongolia’s health system has been in transition. Impressive gains have been accomplished through a national immunization program, which was instituted in 1991. Nevertheless, the country continues to confront four major chronic infections: hepatitis B and C, brucellosis, tuberculosis, and sexually transmitted diseases (STDs). As of 2001, only two cases of HIV infections had been detected in Mongolia, but concern grows that the rate will increase along with the rising rates of STDs and increase in tourism. Other infectious diseases of importance in Mongolia include echinococcus, plague, tularemia, anthrax, foot-and-mouth, and rabies.

Acute erosive reactive arthritis associated with campylobacter jejuni-lnduced colitis

A case of acute erosive, reactive arthritis following Campylobacter jejuni-induced ulcerative colitis is presented. This is the 12th such case reported in the literature and the first in which destructive lesions of periarticular bone are demonstrated. A review of the literature suggests that reactive arthritis associated with C. jejuni infection is similar to that following other invasive types of bacterial diarrhea and is often associated with HLA-B27 lymphocyte antigen.

Spinal Epidural Lipomatosis in a Human Immunodeficiency Virus-Positive Patient Receiving Steroids and Protease Inhibitor Therapy

We describe a patient who became cushingoid as a result of receiving steroid therapy for thrombocytopenia purpura and who then developed spinal epidural lipomatosis 4 months after he started receiving ritonavir as part of his therapy for human immunodeficiency virus infection. We believe that ritonavir may have contributed to the development of epidural lipomatosis and that clinicians should be aware of this possible association.

Gonococcal endocarditis associated with immune complex glomerulonephritis

A case is described in which chronic gonococcemia probably resulted in endocarditis, nephrotic syndrome and diffuse immune-complex glomerulonephritis. This is the 11th case of gonococcal endocarditis reported since 1948 and the first report with accompanying immunofluorescence and electron microscopy of the kidney. These studies revealed immune-complex nephritis to be the likely cause of the patients deteriorating renal function.

Chronic venous insufficiency in HIV-positive persons with and without a history of injection drug use.

OBJECTIVE: To examine chronic venous insufficiency in human immunodeficiency virus-positive persons with and without a history of injection drug use and to examine the extent to which neuropathy further increased the risk of chronic venous insufficiency. DESIGN: Cross-sectional stratified design with quota sampling. SETTING: Infectious diseases clinic in a large, urban midwestern city. PARTICIPANTS: Human immunodeficiency virus-positive persons, 27 with no history of injection drug use and 46 with a history of injection drug use, who met the inclusion criteria, including being 30 to 65 years of age, not pregnant, and willing to respond to a questionnaire and have their lower legs examined, were enrolled until the quota for each stratum (no injection drug use and injection drug use) was filled. MAIN OUTCOME MEASURES: Chronic venous insufficiency clinical classification, injection drug use history, and presence of peripheral neuropathy. MAIN RESULTS: Sixty-one percent of injection drug users (28/46) presented with severe chronic venous insufficiency compared with 11% (3/27) of noninjection drug users (P< .001). The presence of lower extremity neuropathy was not significantly related to chronic venous insufficiency classification. CONCLUSIONS: This is the first study to report the high risk of chronic venous insufficiency in human immunodeficiency virus-infected persons who inject drugs. Chronic venous insufficiency should be assessed in human immunodeficiency virus-positive persons when there is a history of injection drug use, and measures to protect the legs should be implemented.

Non-Surgical Management of Post-Cesarean Endomyometritis Associated With Myometrial Gas Formation

We present a case of post-cesarean delivery, nonclostridial endomyometritis in which uterine (myometrial) gas formation raised concern for myonecrosis and need for hysterectomy. The patient fully recovered without surgery. Myometrial gas formation in this setting and in an otherwise stable patient may be an insufficient reason for hysterectomy.

To the Editor.—-Reply

—Dr Silberstein points out that the low specificity of 67 Ga scans that we recently reported was caused, in large part, by nonspecific accumulation of 67 Ga in the GI tract. He further states that the specificity would have been improved had we obtained follow-up scans to see the radionuclide cleared from the intestine. Although we agree that specificity may have been improved had we obtained 72- and, possibly, 96-hour images, we hasten to make the following points: (1) other major medical centers are experiencing results similar to ours with 67 Ga (see the accompanying letter from Drs McDougall and Goodwin), and (2) the possibility of increasing specificity of 67 Ga scanning by obtaining 72- and 96-hour images is accompanied by a frequently unacceptable delay in providing meaningful results to the clinician. We, therefore, share Silbersteins as well as McDougall and Goodwins interest in 111 In—labeled oxyquinoline WBC scans in