Robert Tight

Urinary Tract Infections with Antibiotic Resistant Organisms in Catheterized Nursing Home Patients

Long-term use of indwelling urinary catheters in nursing home (NH) patients is a potential cause of significantly morbidity. We retrospectively studied 10 NH patients with chronic indwelling urinary catheters. Sixty-four percent of all 84 antibiotic courses prescribed were for bacteriuria alone without clinical infection. Seventy percent of 63 antibiotic courses were followed by bacteriuria with organisms resistant to the antibiotic administered. Bacteria isolated from NH patients often displayed greater resistance to specific antibiotics than those isolated from hospitalized patients. Four of the 20 urinary tract infections were associated with bacteremia. Three episodes of bacteremia were with highly-resistant organisms and one was fatal. Use of urinary catheters and inappropriate use of antibiotics in NH patients results in urinary tract colonization and infection with resistant bacteria and is an important cause of morbidity and mortality.

Anaerobic spondylodiscitis: Case series and systematic review

Background: Bacterial spondylodiscitis is rarely caused by anaerobic organisms. We describe two patients with lumbar vertebral osteomyelitis and discitis caused by anaerobic bacteria, including an unusual occurrence after an endodontic procedure, and review the salient clinical features and outcomes of 31 previously reported cases. Methods: Case reports and review of the literature. Results: Median age at presentation was 65 years, with a male-to-female ratio of 2:1. The most common presenting symptoms were back pain, fever, and neurologic deficits. The lumbar spine was most frequently involved (43%); an equal number of cases involved contiguous extension or hematogenous spread. Causative anaerobes were recovered from disk space or vertebrae (13), blood (4), and/or soft tissue abscess and included Bacteroides species (12), Propionibacterium acnes (7), Peptococcus species (4), Peptostreptococcus species and Clostridium species (3 each), Corynebacterium diphtheroides and Fusobacterium species (2 each), and unspecified anaerobes (3). Conclusions: Apart from specific antibiotic selection, medical treatment and outcomes for anaerobic spondylodiscitis are similar to those for aerobic vertebral disk infection.

Comparison of once-daily versus pharmacokinetic dosing of aminoglycosides in elderly patients

PURPOSE Once-daily dosing has been suggested as an alternative method of dosing aminoglycosides that would reduce their toxicity while maintaining efficacy. There have been no studies published to date comparing once-daily dosing and pharmacokinetic dosing of aminoglycosides. We conducted a randomized controlled trial comparing the safety and effectiveness of 4 mg/kg IV once-daily dosing of gentamicin or tobramycin with a pharmacokinetic dosing method using an initial dose of 2 mg/kg IV every 12 hours. PATIENTS AND METHODS Ninety-six patients were randomly assigned to either the once-daily dosing group (4 mg/kg) or the pharmacokinetic dosing group (initial dose of 2 mg/kg every 12 hours). In the once-daily dosing group, the dosing interval was extended by 12 to 24 hours to maintain a serum trough concentration < 1.5 mg/L regardless of the peak concentration. Dosing in the other group was adjusted based on the individual pharmacokinetic data to achieve a serum peak concentration of 6 to 10 mg/L and a trough concentration below 1.5 mg/L. The patients studied were predominantly elderly males (mean age 69 years). All patients were assessed for treatment efficacy and nephrotoxicity. RESULTS There was no significant difference between the two groups with regard to clinical and bacteriologic efficacy. Incidence of nephrotoxicity was 24% in the once-daily group and 14% in the pharmacokinetic dosing group but the difference was not statistically significant (P = 0.13). Unlike previous studies, we found a correlation between high serum peak concentration and incidence of nephrotoxicity in the once-daily dosing group. Nephrotoxicity developed in six out of 10 patients (60%) with an initial serum peak concentration greater than 12.0 mg/L compared to two out of 24 patients (8.3%) with an initial peak concentration less than 12.0 mg/L (P < 0.001) in the once-daily group. Serum peak concentrations in the pharmacokinetic dosing group were not correlated with nephrotoxicity. CONCLUSIONS Once-daily dosing and pharmacokinetic dosing of aminoglycosides appear to have equal efficacy and toxicity. However, in the elderly population, high serum peak concentrations that occur with once-daily aminoglycoside dosing may increase the risk of nephrotoxicity.

Recurrent Blastomycosis of the Central Nervous System: Case Report and Review

Although blastomycosis of the central nervous system (CNS) occurs in approximately 4% of patients with blastomycosis, recurrent CNS blastomycosis is very rare. We review the clinical features, treatment, and outcome of 4 previously reported cases. We also report a case of recurrent CNS blastomycosis successfully treated with surgery and liposomal amphotericin B after an inadequate response to amphotericin B therapy. This treatment may be an alternate approach for management of similar cases.

Human Infection with Herpes Zoster: Etiology, Pathophysiology, Diagnosis, Clinical Course, and Treatment

Herpes zoster is a cutaneous vesicular eruption resulting from recrudescence of the chickenpox virus. It is mainly a disease of adults, with a predisposition for the elderly or immunocompromised. Although usually localized, the disease can disseminate to visceral organs. Diagnosis is often made based on the characteristic pattern of the lesion and clinical features. Tzanck smear, viral isolation, seroconversion, antibody titers, and monoclonal antibodies may further aid or confirm the diagnosis. Clinical features of herpes zoster may follow a progression through 3 stages, prodromal, acute, and chronic. The prodromal and acute phases seldom require more than symptomatic management. The chronic pain syndrome, postherpetic neuralgia (PHN), demands a more aggressive approach. Pharmacologic intervention, neuroaugmentation, and/or surgery may prevent or alleviate PHN, but universal response to any of these therapeutic approaches is unlikely. Tricyclic antidepressants remain the first choice in treating this pain syndrome. A trial of antiviral therapy may be warranted in patients with disseminated disease or in immunocompromised patients with localized disease. Of the antiviral agents, acyclovir is considered the drug of choice by most clinicians.

Plasma Cell Pleocytosis in Cerebrospinal Fluid in Patients with West Nile Virus Encephalitis

We describe 4 patients with West Nile virus encephalitis who all displayed previously unreported plasma cell pleocytosis of the cerebrospinal fluid (CSF). Three patients recovered but had varying degrees of mild neurologic disability on discharge from the hospital, and 1 patient died. The finding of significant numbers of plasma cells in CSF may serve as a useful early diagnostic clue for West Nile virus encephalitis.

Female genital coccidioidomycosis (FGC), Addison's disease and sigmoid loop abscess due to Coccidioides immites; case report and review of literature on FGC.

We describe a woman with unusual complications of infection with Coccidioides immitis - infection of the genital tract and adrenal insufficiency. The patient also had intestinal coccidioidomycosis (cocci) in conjunction with presumed pulmonary, and asymptomatic central nervous system cocci. To our knowledge, concurrent FGC, intestinal and adrenal cocci have not been reported previously. A MEDLINE review from 1966–1997 revealed only 1 case of adrenal insufficiency due to cocci. FGC is rare; we identified 12 reported cases since 1929. No combination of investigations or clinical features is sensitive enough to predict FGC. Diagnosis is usually made after microscopy of surgical specimens. FGC presents either as tubo-ovarian disease or endometritis. Treatment generally involves surgical excision and antifungal agents. We hypothesize that an initial trial of antifungals may obviate the need for surgery.