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Background: In patients with moderate to severe histoplasmosis associated with AIDS, the preferred treatment has been the deoxycholate formulation of amphotericin B. However, serious side effects are associated with use of amphotericin B. Objective: To compare amphotericin B with liposomal amphotericin B for induction therapy of moderate to severe disseminated histoplasmosis in patients with AIDS. Design: Randomized, double-blind, multicenter clinical trial. Setting: 21 sites of the U.S. National Institute of Allergy and Infectious Diseases Mycoses Study Group. Patients: 81 patients with AIDS and moderate to severe disseminated histoplasmosis. Measurements: Clinical success, conversion of baseline blood cultures to negative, and acute toxicities that necessitated discontinuation of treatment. Results: Clinical success was achieved in 14 of 22 patients (64%) treated with amphotericin B compared with 45 of 51 patients (88%) receiving liposomal amphotericin B (difference, 24 percentage points [95% CI, 1 to 52 percentage points]). Culture conversion rates were similar. Three patients treated with amphotericin B and one treated with liposomal amphotericin B died during induction (P=0.04). Infusion-related side effects were greater with amphotericin B (63%) than with liposomal amphotericin B (25%)(P=0.002). Nephrotoxicity occurred in 37% of patients treated with amphotericin B and 9% of patients treated with liposomal ampotericin B (P=0.003). Conclusion: Liposomal amphotericin B seems to be a less toxic alternative to amphotericin B and is associated with improved survival.

Several factors can affect the effectiveness of antibiotic therapy among patients with critical conditions. These include varying drug chemistry activity at different body locations and with different organisms, unidentified drug resistance, the presence of underlying conditions, and the need for supplemental interventions. Re-evaluation may be necessary for unresponsive infections.

Patients taking fluconazole for fungal infections may experience temporary hair loss as a side effect while taking the medication. Researchers reviewed the medical information of 33 patients taking fluconazole who had experienced some hair loss. The daily dose of fluconazole ranged from 100 milligrams (mg) weekly to 800 mg daily with most patients (88%) taking at least 400 mg of fluconazole every day for an average of 7.1 months. All 33 patients had experienced some scalp hair loss while 10 patients had additional hair loss either from the chest, underarms, legs, pubic area, or face. Three patients had so much scalp hair loss that they needed a wig. Patients noticed hair loss an average of 3.2 months after starting to take the drug. Hair began growing again after discontinuing therapy and was back to normal an average of 6 months later.

* Study Objective. -- The purpose of this study was to assess and compare the impact of voluntary compliance and enforced compliance with institutional guidelines for initiating third-generation cephalosporin therapy. Design. -- An audit of third-generation cephalosporin use during a 6-month period shortly after ceftriaxone and ceftazidime were added to the hospital formulary already containing cefotaxime was performed. During this period, compliance to institutional guidelines for initiating therapy was voluntary. A follow-up audit during a similar 6-month period was performed to assess compliance with institutional guidelines shortly after an enforcement policy was placed in effect. The results of these two audits were compared to assess usage patterns of those cephalosporins, compliance rates with institutional guidelines for initiating therapy, use of susceptibility testing to guide therapy, effect of use of these drugs on susceptibility patterns within the hospital, and third-generation cephalosporin costs during periods when institutional policy was unenforced and enforced. Results. -- Only 24.2% of 66 courses of third-generation cephalosporins were initiated in compliance with institutional during the initial audit period. Susceptibility testing revealed an organism susceptible to a first-generation cephalosporin in 13 courses but in only six instances was a switch to the more narrow-spectrum antibiotic performed. At the time routine susceptibility testing to ceftazidime and ceftriaxone was instituted, 92% of Enterobacter cloacae were sensitive to ceftriaxone and 89% of Pseudomonas aeruginosa were sensitive to ceftazidime. Fifteen months later, when voluntary compliance to institutional policy was terminated, 70% of E cloacae were sensitive to ceftriaxone and 73% of P aeruginosa were sensitive to ceftazidime. During the last 6 months of this period, pharmacy expenditures totaled $50 000. The second audit revealed 85.4% of 48 courses of treatment complied with guidelines for initiating therapy. Since enforcement was instituted, sensitivity of E cloacae to ceftriaxone has risen to 88% and sensitivity of P aeruginosa to ceftazidime has increased to 80%. Pharmacy expenditures decreased to $23 000. (Arch Intern Med. 1992;152:554-557)

Edited by R. L. Nichols, N. E. Hyslop, and J. g. Bartlett. Philadelphia: BC Decker, 1991, 389 pp, $59.50 This book is part of a series of surgical titles in [...]