Shirin A. Mazumder

Bordetella bronchiseptica bacteremia in a patient with AIDS.

Bordetella bronchiseptica bacteremia is often associated with various infection in animals. The majority of B bronchiseptica infections reported in humans are cases of pneumonia. Very few cases have been reported in patients with a history of acquired immune deficiency syndrome (AIDS). The patient described herein, who had a history of AIDS, was likely infected with B bronchiseptica as a result of his hemodialysis catheter. The patient was successfully treated with antibiotics without the removal of the catheter.

Successful treatment with doripenem and tobramycin of ventriculitis due to imipenem- and meropenem-resistant Pseudomonas aeruginosa

Inoculum suspensions were prepared from 7 to 14 day cultures on potato carrot agar, by slightly scraping the surface of mature colonies with a sterile cotton swab wetted with sterile saline including Tween 40 (0.05%). The super-natants were adjusted spectrophotometrically at a wavelength of 530 nm to an optical density (OD) that ranged from 0.25 to 0.3 (2Â10 4 –7Â10 4 cfu/mL). 3 Microdilution plates were incubated at 308C for 48 h (plates with insufficient growth were incubated for 72 h) and read visually after agitation. Table 1 summarizes the results of all in vitro activities of the eight antifungal drugs. Both environmental and clinical Alternaria isolates showed an MIC range from 0.125 to 1 mg/L for amphotericin B. We found the widest range and the highest MICs for fluconazole (range 4– 32 mg/L). Surprisingly, most isolates of A. infectoria and A. alternata had high MICs of voriconazole, although the environmental isolates of A. malorum (a non-human pathogenic species) had lower MICs. Isavuconazole had high MICs similar to voriconazole with complete inhibition endpoints exhibiting MIC 50 and MIC 90 values of 4 mg/L against all Alternaria isolates. Itraconazole demonstrated better in vitro activity than vori-conazole and isavuconazole with an MIC 90 of 1 mg/L. Posaconazole had the lowest MIC 90 (0.25 mg/L) of all the azoles. The echinocandin drugs caspofungin and anidulafungin both demonstrated in vitro activity against A. infectoria and A. alternata, with anidulafungin exhibiting the lowest MEC 90 (0.008 mg/L) compared with caspofungin (MEC 90 1 mg/L); MEC stands for minimal effective concentration. Both echino-candins had no activity against A. malorum (MEC 90 .8– 16 mg/L). More than 150 cases of infection have been described in the world literature, with the skin being the most involved organ. 1 Severe deep infections are rare complications and optimal treatment is not known. 2 Various antifungal drugs have been used in the treatment of Alternaria infection, such as amphotericin B, flucytosine, fluconazole, miconazole and nystatin. 1 There are few published data available concerning the in vitro antifungal susceptibility with microdilution techniques of Alternaria species; 4,5 the largest collection included just 13 strains. 4 Reported MIC 50 and MIC 90 values of posaco-nazole, itraconazole and amphotericin B are comparable to our results. Among the azoles, fluconazole showed uniform low activities against Alternaria species in this and previous studies. 4,5 Except one report involving 11 isolates, 5 itracona-zole, voriconazole and posaconazole had good …

Association of Raoultella bacteremia with diseases of the biliary tract

The report by De Jong et al. [1] of several cases of Raoultella bacteremia associated with biliary disease was interesting to us as we recently encountered a similar patient. A 66-y-old woman with unresectable pancreatic cancer was admitted with nausea, emesis, increasing weakness, and neutropenic fever several days after beginning her second cycle of FOLFOX chemotherapy (folinic acid, fl uorouracil, and oxaliplatin). There was no history of fl ushing or recent fi sh ingestion. Other than a temperature of 39 ° C, her physical examination (including abdominal examination) was unremarkable. Her absolute neutrophil count was 150 cells/mm 3 . An abdominal computed tomogram did not reveal abscess or air. Empiric antibiotic therapy with piperacillin – tazobactam 3.375 g intravenously every 6 h was begun. Blood cultures obtained at admission grew Raoultella ornithinolytica and Escherichia coli. Subsequent blood cultures demonstrated clearing of both organisms. Despite this apparent response to treatment of her infection, her condition continued to deteriorate and her family opted for palliative care. She died 18 days after admission. While reviewing materials related to Raoultella spp. we noted many of the same materials referenced by De Jong et al. [1]. Additionally we noted several other reported cases of bacteremia due to Raoultella spp. These are summarized in Table I [2 – 5]. As described by De Jong et al. [1], many of these cases are associated with biliary disease. Also striking to us is the possible association with malignant processes that may have involvement of the biliary and/ or pancreatic system. Bile acids have previously been shown to be tumor promoters, and increased ornithine decarboxylase activity has been noted with rapid cell proliferation [6]. The importance of the biliary system and any impact of neoplastic processes on that system and its suitability as a milieu for growth of Raoultella spp. remain to be seen.

Scedosporium apiospermum infection presenting as a pneumothorax and cavitary lung lesions in a patient with acquired immune deficiency syndrome.

The Scedosporium genus consists of filamentous fungi that inhabit soil, sewage, manure, and polluted waters, and contains two medically important species: Scedosporium apiospermum and Scedosporium prolificans. Scedosporiosis is caused by inhalation or traumatic subcutaneous implantation of the organism, and may have varied clinical presentations. A variety of pulmonary manifestations can occur, but to our knowledge, pneumothorax as initial presentation has not been reported. Treatment may be difficult, as the disease occurs more commonly in immunocompromised patients, and the organism may demonstrate resistance to various antifungal agents. We describe successful treatment of extensive pulmonary disease due to S apiospermum in a patient with acquired immune deficiency syndrome (AIDS).

Fatal Yarrowia lipolytica Intra-abdominal Abscess with Persistent Fungemia in a Liver Transplant Recipient

Yarrowia lipolytica is a dimorphic fungus formerly named Candida lipolytica. Although candidemia is commonly encountered, fungemia due to Y. lipolytica is uncommon and is usually a relatively benign catheter-associated phenomenon. We report the first case of intraabdominal abscess and persistent fungemia due to Y. lipolytica, which, unfortunately, was fatal in a liver transplant recipient.

Minocycline for the treatment of community-acquired Staphylococcus aureus infections.

Age −0.005 (−0.083, 0.072) 0.893 Sex 1.215 (−0.711, 3.141) 0.215 HD experienceb −0.005 (−0.023, 0.013) 0.598 Height −0.128 (−0.241, −0.015) 0.027* Weight −0.192 (−0.274, −0.110) <0.001* 0.110 (0.025, 0.196) 0.012** Oliguriac −3.893 (−6.535, −1.250) 0.004* Loading dose/BW (mg/kg) 0.612 (0.494, 0.730) <0.001* 0.506 (0.381, 0.630) <0.001** Maintenance dose/BW (mg/kg) 1.100 (0.843, 1.358) <0.001* 0.894 (0.596, 1.192) <0.001** Time since first vancomycin dose 1.139 (0.165, 2.113) 0.022* Ultrafiltration (kg) 0.475 (−0.651, 1.600) 0.406 Duration of HD sessions (h) 1.721 (−0.114, 3.556) 0.066

Differential diagnosis of a patient with rhomboencephalitis: Case study

Rhomboencephalitis is a rare and severe infection that frequently presents as progressive brainstem dysfunction. Most cases reported in the medical literature are associated with a positive and specific microbial etiology that is clearly documented by blood, cerebrospinal fluid (CSF), or brain tissue culture. However, some patients with rhomboencephalitis have a negative culture workup, which can lead to a delay in treatment initiation as a differential diagnosis is made. Because a high mortality rate has been associated with a delay in antibiotic therapy for patients with rhomboencephalitis, an improved index of suspicion is needed for early diagnosis.Recently, the authors cared for a patient with a culture-negative rhomboencephalitis that was successfully treated with empiric antibiotic management. The patient was a 36-year-old woman with symptoms of fever, nausea, and dysphagia. Imaging revealed a right-sided intra-axial contrast-enhancing lesion at the pontomedullary junction, but an exhaustive laboratory and imaging workup failed to reveal a definite etiology. The patient was then given a 6-week course of meropenem, linezolid, and acyclovir to cover possible pathogens, and she ultimately made a complete neurological recovery.

Bacteriuria in Delirious Individuals

With interest we read the commentary by McKenzie et al about bacteriuria and delirium. Although we believe the authors are absolutely correct in arguing for the lack of benefit of antibiotic therapy in asymptomatic bacteriuria in elderly patients, they may misinterpret the main impetus for antibiotic prescribing for delirious elderly patients with an abnormal urinalysis or a positive urine culture. Many, if not most, prescribers are cognizant of the lack of benefit in treating asymptomatic bacteriuria in the elderly. Based on our discussions with many colleagues who treat this patient population, their foremost concern is that of possible urosepsis with delirium as a manifestation, and not just an asymptomatic bacteriuria. Given the relative frequency with which septic elderly patients clinically present with lack of fever or leukocytosis, physicians are left with no sensitive and specific means of distinguishing early urosepsis with delirium from delirium of another etiology with accompanying irrelevant asymptomatic bacteriuria.

Common Use of the Empirical Combination of Vancomycin and a β-Lactam for Staphylococcal Bacteremia

TO THE EDITOR—The recent discussion by McConeghy et al of treatment for staphylococcal bacteremia using an empirical combination of vancomycin and a βlactam was insightful [1]. They and other investigators have speculated that using initial empirical coverage with activity against bothmethicillin-resistant Staphylococcus aureus and methicillin-susceptible S. aureus (MSSA) may lead to improved clinical outcomes [2, 3]. Empirical antibacterial coverage including vancomycin and β-lactam antibiotics with significant coverage for gram-negative pathogens has been reported with varying frequency [4, 5]. At our institution, we frequently encounter patients with a variety of indications (sepsis, fever, skin and skin structure infections, pneumonia, and others) who are receiving empirical therapy with vancomycin plus either piperacillin/tazobactam or cefepime. In discussions with multiple infectious disease physicians across the nation, we have commonly heard similar anecdotal observations, although published data in this regard are limited. β-Lactam agents such as piperacillin/ tazobactam and cefepime may offer significant coverage for MSSA as well as for gram-negative organisms [6, 7]. Although these β-lactam antibiotics may not usually be considered as antistaphylococcal drugs as are nafcillin, oxacillin, and cefazolin, their antistaphylococcal activity may already be achieving the objective as suggested by McConeghy et al [1]. Current clinical practice may thus have already accomplished part of the goal McConeghy et al outlined. We caution as well that pressure related to the goal of antimicrobial stewardship may lead to premature de-escalation to vancomycin monotherapy before susceptibility results are known, leading to less desirable clinical outcomes.