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Background: Methicillin-resistant S. aureus (MRSA) with low susceptibility to glycopeptides is uncommon., Case Presentation: The case of a 50-year-old non-drug addict patient presenting with tricuspid valve infective endocarditis (IE) by MRSA resistant to vancomycin and linezolid is presented. There was response only to quinupristin/dalfopristin. He had a motorcycling accident four years before undergoing right above-the-knee amputation and orthopaedic fixation of the left limb. There were multiple episodes of left MRSA-osteomyelitis controlled after surgery and vancomycin therapy. MRSA isolated from the blood at the time of IE presented with the same profile than the isolated four years earlier. Sequential treatment with teicoplanin-cotrimoxazole and Linezolid associated to vancomycin--rifampicin--cotrimoxazole had no improvement. Infection was controlled after 28 days of therapy with quinupristin/dalfopristin., Conclusion: The literature presents only a few cases of MRSA IE not susceptible to glycopeptides in not drug addicted patients. This case shows the comparison of a highly-resistant MRSA after previous S. aureus osteomyelitis treated with glycopeptides. This is the first description of successful treatment of resistant-MRSA IE of the tricuspid valve complicated by multiple pulmonary septic infarction with quinupristin/dalfopristin.

Background: Most patients with acute myocardial infarction (AMI) are admitted to hospitals without percutaneous transluminal coronary angioplasty (PTCA) facilities or are initially managed in a prehospital mobile unit. Thrombolysis remains the most readily available reperfusion treatment in those settings, but the optimal subsequent strategy in those patients is unclear. If a mechanical recanalization is likely to be performed in an emergency, it is probably desirable that the patient receives abciximab, the glycoprotein IIb/IIIa antagonist with the strongest evidence of benefit for angioplasty in AMI., Objective: The aim of this trial is to compare the effects on clinical outcome and cost-effectiveness of 2 strategies after immediate treatment with abciximab and half-dose reteplase for ST-elevation AMI: to manage the patients conservatively (referring them for rescue PTCA only if needed) or to immediately send all patients for emergency coronary angioplasty., Methods: The Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction (CARESS in AMI) is an open, prospective, randomized, multicenter clinical trial conducted in patients with high-risk ST-segment elevation AMI treated within 12 hours from symptom onset in hospitals without PTCA facilities or in a prehospital mobile intensive care unit. Apart from contraindications to thrombolysis, the main exclusion criteria are age > or =75 years and a past history of CABG surgery or a percutaneous coronary intervention procedure involving the infarct-related artery. Enrollment will be performed in hospitals without PTCA facilities or directly in the ambulance if a dedicated system is in place for prehospital diagnosis and treatment of AMI. Patients will receive half-dose reteplase and full-dose abciximab and will subsequently be randomized to conventional medical therapy (with referral for emergency rescue PTCA allowed in selected cases) or emergency angioplasty. The primary end point is the 30-day combined incidence of mortality, reinfarction, and refractory ischemia. In order to obtain a 95% power (2-sided) to detect a 42% reduction in the primary end point, 900 patients are required in each arm of the study. Secondary end points include the 1-year composite end point of mortality, reinfarction, refractory ischemia, and hospital readmission because of heart failure; resource use at 30 days and 1 year; and the incidence of inhospital stroke and bleeding complications in the 2 groups., Results: Seventy-four patients have been randomized (as of March 10, 2004); results are expected in June 2005., Conclusion: This study will establish whether angioplasty must be started as soon as possible in all patients who receive combined pharmacologic reperfusion with the glycoprotein IIb/IIIa inhibitor abciximab and half-dose thrombolysis or whether it can be postponed or skipped in patients with signs of successful reperfusion, with obvious organizational advantages.

Background: The most important limitation in primary percutaneous coronary interventions (PCI) for acute myocardial infarction (AMI) is the small number of catheterization laboratories and their non-homogeneous territorial distribution. The aim of this study was to evaluate the safety and efficacy of an organizational model based on a network including tertiary referral centers and community hospitals for the treatment of AMI with alteplase plus abciximab followed by PCI., Methods: From October to November 2002, 232 patients < or = 75 years with AMI at high risk (84 transferred from four community hospitals and 148 patients admitted directly at the tertiary center) underwent PCI at our Institution. We compared procedural results and clinical outcome in patients with AMI undergoing PCI with or without transfer to tertiary centers., Results: Patient transferal from community hospitals determines a greater door-to-balloon time (120 vs 55 min, p < 0.001), while complications observed during transportation are limited (5.9%). Transferred patients have a greater percentage of infarct-related artery patency (77 vs 22%, p < 0.001) and of ST-segment resolution 90 min post-PCI (77 vs 57%, p < 0.005) in comparison with direct-access patients. The incidence of clinical events (death, reinfarction, angina) was not different between the two groups at 30 days and at 6 months of follow-up., Conclusions: In our experience the integrated model between tertiary centers and community hospitals represents a valid network system offering homogeneous therapeutic (alternatives) options to all patients with AMI regardless of the hospital where they are first admitted.