John Z. Montgomerie

Acute Interstitial Nephritis Due to Methicillin

Fourteen patients are described with a syndrome of methicillin-induced interstitial nephritis. In all patients severe renal dysfunction developed with an average peak serum creatinine of 8 mg/100 ml. An increased total peripheral eosinophil count was found in all patients. All patients had sterile pyuria and each of nine patients studied by Wrights stain of urine sediment had marked eosinophiluria. These findings are suggestive of methicillin-induced interstitial nephritis, although proteinura was a variable finding in our patients. Eight of 14 patients in our study received prednisone therapy for their interstitial nephritis, and the time lapse between maximal and final base line serum creatinine levels was statistically less in the prednisone-treated compared to the nontreated groups. Clinical manifestations of this syndrome are discussed, and the light and electron microscopic and immunofluorescent findings on renal biospy are described.

Quantitative microbiology of pressure sores in different stages of healing

The quantitative microbiology of 25 pressure sores in different stages of healing was examined in 25 patients with spinal cord injury. When grossly necrotic tissue was present (stage 1), 5.8 isolates per patient with a density of 6.4 log10/g was recovered, with comparable findings for aerobes and anaerobes. In the absence of necrotic tissue but with the presence of undermining (stage 2), 1.5 aerobic and 0.2 anaerobic isolates were recovered per patient with a mean density of 2.7 and 0.1 log10/g of tissue for aerobic and anaerobic isolates, respectively. The lesions were almost sterile in patients with no necrotic tissue and no undermining (stage 3). Foul smell was always associated with the presence of anaerobes in deep tissue cultures, however, six patients with nonfoul-smelling lesions yielded anaerobes. A 75% quantitative concordance was seen between swab and biopsy culture results. The quantitative concordance between peripheral and central biopsy culture results was 63%, showing variability in results from different sampling areas. No relationship was observed between the density of microorganisms and the eventual outcome of the myocutaneous flap procedure.

Candida peritonitis: Report of 22 cases and review of the english literature

Thirty-one patients with Candida isolated from peritoneal fluid were examined. Twenty-two were considered to have Candida peritonitis. The data on these 22 patients, plus 12 additional patients described in the literature, were reviewed. This infection was observed as a complication of peritoneal dialysis, gastrointestinal surgery or perforation of an abdominal viscus. Recent antibiotic administration seemed to be an important predisposing factor. The disease usually remained localized intra-abdominally, although disseminated candidiasis was also noted in three cases. Clinically significant infection could be differentiated from peritoneal contamination with Candida by the presence and persistence of fever, peritoneal signs, peripheral leukocytosis, positive peritoneal cultures for Candida, abnormal films of the abdomen and purulent ascitic fluid. Surgical interventions and removal of infected peritoneal fluid were the cornerstones of therapy. Short-term, low-dose systemic and/or intraperitoneally administered amphotericin B appeared promising in the treatment of unremitting infection. Mortality in treated patients was low and was comparable to that in patients with bacterial peritonitis.

Infections in patients with spinal cord injuries.

Approximately 8,000 persons survive spinal cord injury urinary tract infection in patients with SCIs. Performance of intermittent catheterization and bladder-neck manipulation (SCI) each year in the United States. About 200,000 Americans have reduced the morbidity associated with neurogenic bladder. have spinal cord injuries, and this number is increasing as life Changes in the bladder associated with the long-term use of expectancy increases towards normal levels for these persons. indwelling catheters include squamous metaplasia, thickening Nosocomial infection is common in patients with SCIs because and fibrosis of the bladder, diverticula, calculi and the presence these patients are admitted to the hospital immediately after of multiple organisms, alkaline-encrusting cystitis with ureasetheir injuries occur, and they stay for a considerable time for producing bacteria, penile and scrotal fistulae, abscesses and management of the injuries and for rehabilitation. Because of epididymitis, and squamous cell carcinoma of the bladder. the prolonged stay, these patients are at greater risk of develIntermittent catheterization is associated with an increased oping infections with resistant microorganisms including methincidence of bacteriuria, which may be influenced by the freicillin-resistant Staphylococcus aureus (MRSA) and multiresisquency of catheterization. As the interval between catheterizatant gram-negative bacilli. Patients with SCIs frequently have tions increases, the incidence of bacteriuria may increase. Pawounds on the neck, chest, or abdomen and often are at additients who are unable to perform intermittent catheterization tional risk from surgery and the use of blood products. High themselves are also at greater risk of infection [2]. doses of corticosteroids, given immediately after injury, may A wide range of microorganisms has been isolated from predispose these patients to infection as well as to upper gastropatients with SCIs and urinary tract infections. The presence intestinal complications [1]. After discharge from the hospital of bacteria that are urease producers raises concerns about and rehabilitation, the incidence of infection, usually of the calculus formation. Infection due to Escherichia coli strains urinary tract, respiratory tract, and infected pressure ulcers, that may be more virulent than other strains has not been continues to be increased for patients with SCIs. well studied. The virulence of some bacterial species, such as Pseudomonas, in the urinary tracts of patients with SCIs has Urinary Tract Infections been questioned, but there are sufficient data showing that tissue invasion and bacteremia with Pseudomonas aeruginosa Bacteriuria is almost universal in patients with SCIs. This are not uncommon. infection may be asymptomatic colonization, but tissue invaE. coli and species of Pseudomonas, Klebsiella, and Enterosion of the urinary tract occurs in most patients initially during coccus have been the predominant microorganisms that cause hospitalization and rehabilitation and may be a recurrent proburinary tract infections in patients with SCIs. A high prevalence lem for most of these patients throughout their lives. At one of Proteus species, which may relate to the more frequent time, these infections were the dominant cause of bacteremia, use of indwelling catheters, has been noted at some centers. renal failure, and death among patients with SCIs until the Klebsiella, Pseudomonas, and Proteus species tend to be more methods of urinary drainage improved; however, serious comresistant than E. coli to commonly used antibiotics, but outplications, bacteremia, calculi, pyelonephritis, and renal failure breaks of infection with multiresistant gram-negative bacilli still occur. have been described relatively infrequently in SCI units. An increased volume of residual urine and increased bladder A patient’s sex and level of injury may affect the microbiolpressure have been the most important factors responsible for ogy of bacteriuria and colonization. At our institution, the incidence of infection with Klebsiella and Pseudomonas species among male patients has been high, which may be related to the use of external condom catheters. In one study of female Received 16 July 1997. patients with SCIs who underwent intermittent catheterization, Reprints or correspondence: Dr. John Z. Montgomerie, Rancho Los Amigos Medical Center, 7601 East Imperial Highway, 244 HB, Downey, California E. coli and Enterococcus species accounted for 71% of infec90242. tions [3]. Clinical Infectious Diseases 1997;25:1285–92 Because of loss of sensation, patients with SCIs do not have q 1997 by The University of Chicago. All rights reserved. 1058–4838/97/2506–0001

Leukocyte phagocytosis and serum bactericidal activity in chronic renal failure.

03.00 the common symptoms of urinary tract infection such as fre-

The 28K protein in urinary bladder, squamous metaplasia and urine is triosephosphate isomerase

Polymorphonuclear leukocytes from patients with chronic renal failure had an impaired ability to engulf Bacillus subtills when compared with polymorphs from normal subjects. Serum from uremic patients killed Escherichia coli and two strains of Staphylo-coccus aureus loss readily than normal serum. An unexpected finding was the increased killing of B. subtilis by scrum from patients with chronic renal failure. L-forms of Strepto-coccus faecalis were equally susceptible to uremic and normal serum. Serum complement levels were not significantly different from those of normal persons. The findings are consistent with the increased susceptibility of uremic subjects to infections.

Persistence of polymicrobial abscesses in the poorly controlled diabetic host

OBJECTIVES The objective of this study was to establish the identity of a protein found in high concentrations in squamous metaplasia of the bladder. DESIGN AND METHODS The protein was isolated and subjected to a series of physical, chemical, and catalytic studies. RESULTS In the normal urothelium the protein was confined to a juxtanuclear pattern on the luminal side of the umbrella cells; in squamous metaplasia and squamous cell carcinoma the protein was increased and exhibited a more diffuse intracellular distribution. The protein was found to be identical to triosephosphate isomerase (EC 5.3.1.1; TPI) with respect to its immunological properties, native and subunit molecular weights, electrophoretic mobility, catalytic activity, and amino acid sequence. CONCLUSIONS While the basis for the altered distribution of TPI remains to be established, the increased amounts of the protein in urine or bladder tissue may be indicative of squamous metaplasia, squamous cell carcinoma, or other bladder injuries.

Effect of External Urinary Collection System on Colonization and Urinary Tract Infections with Pseudomonas and Klebsiella in Men with Spinal Cord Injury

Polymicrobial infections are frequently found in soft tissue infections of the lower extremities in diabetic patients. The relative susceptibility to and persistence of soft tissue polymicrobial infections of diabetic and nondiabetic mice using bacteria commonly found in clinical foot infections were studied. Subcutaneous abscesses were induced in three groups of diabetic and nondiabetic mice using: (1) E. coli and enterococcus, (2) enterococcus and Bacteroides fragilis (B. fragilis), and (3) E. coli and B. fragilis. Abscesses were removed at 1 and 2 wk for total colony counts. At 1 wk, there was a significantly greater bacterial growth in the abscesses of the diabetic mice compared with the nondiabetic mice only in the group injected with enterococcus and B. fragilis. There were significantly higher colony counts in the diabetic compared with the nondiabetic mice in all three groups at 2 wk after injection of the bacteria. Two weeks after injection of inocula containing B. fragilis, both in combination with E. coli or enterococcus, all nondiabetic mice had eradicated B. fragilis from the abscesses, but significant numbers of B. fragilis persisted in the abscesses of the diabetic mice. In the diabetic mice, the presence of enterococci was more synergistic for growth of B. fragilis than was the presence of E. coli. These studies demonstrate that the bacteria of polymicrobial soft tissue infections persist for a longer period of time in the diabetic compared with the nondiabetic host. In addition, B. fragilis has increased pathogenicity in the diabetic compared with the nondiabetic host, particularly in the presence of enterococci.

Methicillin-resistant Staphylococcus aureus bacteriuria

Urinary tract infection of men with spinal cord injuries has been associated with a high incidence of colonization of the patients with gram-negative bacilli. We have examined the factors influencing colonization of 119 patients with Pseudomonas and Klebsiella and studied methods of reducing this colonization. The urethra, perineum, rectum, and drainage bag of all patients were cultured on selective media at two week intervals until discharge. The use of the external urinary collection system (EUCS) was discontinued in a group of patients at night, in an attempt to reduce colonization. Pseudomonas and Klebsiella were isolated from one or more body sites in 65 percent and 69 percent of total culture days. The urethra, perineum, rectum, and drainage bags were reservoirs of Pseudomonas and Klebsiella in men with spinal cord injuries, even in the absence of urinary tract infections. The EUCS proved to be an important factor influencing colonization. Pseudomonas and Klebsiella colonization was higher in patients using the EUCS. Removal of the EUCS at night reduced urethral colonization with Pseudomonas, but did not significantly reduce urethral colonization with Klebsiella. The prevalence of bacteriuria with Pseudomonas and Klebsiella was not significantly influenced by the use of the EUCS.

Ciprofloxacin-resistant Escherichia coli emerging in a rehabilitation medical center

Methicillin-resistant Staphylococcus aureus (MRSA) bacteriuria was detected in 11 of 41 patients colonized or infected with MRSA. The patients with bacteriuria generally were older than 40 years of age, five were diabetic, seven had prior indwelling urethral catheters, two had undergone other urologic manipulations, and only one was clinically symptomatic. Eight patients received variable combinations of antibiotic therapy prior to the diagnosis of MRSA bacteriuria, and seven were still on antibiotic therapy at the time the bacteriuria was detected. Bacteriuria lasted four days to 14 weeks, and was eradicated promptly with cephalosporin therapy in five of six patients. Bacteriuria in the untreated patients cleared spontaneously in one month. A single MRSA serotype (83A) predominated. The MRSA isolates were resistant in vitro to most antibiotics except vancomycin. Resistant colonies were observed within cephalothin disc zones of inhibition at 30C (resistance was confirmed by microtube-dilution sensitivity testing). MRSA disc sensitivity testing for cephalothin may be unreliable when performed at 35C. (Am J Med Sci 281(2):101–109.)