Search

Patients with allergic bronchopulmonary aspergillosis may benefit from the anti-fungal drug itraconazole. Allergic bronchopulmonary aspergillosis is an infection of the lungs by the fungus Aspergillus fumigatus. Researchers randomly assigned 55 patients with allergic bronchopulmonary aspergillosis to take itraconazole or a placebo every day for 16 weeks. Almost half the patients taking itraconazole experienced an improvement in symptoms and were able to reduce their corticosteroid dose. Only 19% of the placebo group improved. The drug caused no more side effects than the placebo.

Poor retention in HIV care is associated with higher morbidity and mortality and greater risk of HIV transmission. The Patient-Centered HIV Care Model (PCHCM) integrated community-based pharmacists with medical providers. The model required sharing of patient clinical information and collaborative therapy-related action planning. The proportion of persons retained in care (≥1 medical visit in each 6-month period of a 12-month measurement period with ≥60 days between visits), pre- and post-PCHCM implementation, was modeled using log binomial regression. Factors associated with post-implementation retention were determined using multi-variable regression. Of 765 enrolled persons, the plurality were male (n = 555) and non-Hispanic black (n = 331), with a median age of 48 years (interquartile range = 38–55); 680 and 625 persons were included in the pre- and post-implementation analyses, respectively. Overall, retention improved 12.9% (60.7–68.5%, p = 0.002). The largest improvement was seen among non-Hispanic black persons, 22.6% increase (59.7–73.2%, p < 0.001). Persons who were non-Hispanic black [adjusted risk ratio (ARR) 1.27, 95% confidence interval (CI) 1.08–1.48] received one or more pharmacist–clinic developed action plan (ARR 1.51, 95% CI 1.18–1.93), had three or more pharmacist encounters (ARR 1.17, 95% CI 1.05–1.30), were more likely to be retained post-implementation. In the final multi-variable models, only race/ethnicity [non-Hispanic black (ARR 1.27, 95% CI 1.09–1.48) and "other or unknown" race/ethnicity (ARR 1.36, 95% CI 1.14–1.63)] showed an association with post-implementation retention. PCHCM demonstrated how collaborations between community-based pharmacists and primary medical providers can improve retention in HIV care. This care model may be particularly useful for non-Hispanic black persons who often are less likely to be retained in care. [ABSTRACT FROM AUTHOR]

Although the annual incidence of bacterial meningitis in the United States is declining, it remains a medical emergency with a potential for high morbidity and mortality. Clinical signs and symptoms are unreliable in distinguishing bacterial meningitis from the more common forms of aseptic meningitis; therefore, a lumbar puncture with cerebrospinal fluid analysis is recommended. Empiric antimicrobial therapy based on age and risk factors must be started promptly in patients with bacterial meningitis. Empiric therapy should not be delayed, even if a lumbar puncture cannot be performed because results of a computed tomography scan are pending or because the patient is awaiting transfer. Concomitant therapy with dexamethasone initiated before or at the time of antimicrobial therapy has been demonstrated to improve morbidity and mortality in adults with Streptococcus pneumoniae infection. Within the United States, almost 30 percent of strains of pneumococci, the most common etiologic agent of bacterial meningitis, are not susceptible to penicillin. Among adults in developed countries, the mortality rate from bacterial meningitis is 21 percent. However, the use of conjugate vaccines has reduced the incidence of bacterial meningitis in children and adults. [ABSTRACT FROM AUTHOR]

Because of high incidence, morbidity, and antimicrobial resistance, Staphylococcus aureus infections are a growing concern for family physicians. Strains of S. aureus that are resistant to vancomycin are now recognized. Increasing incidence of unrecognized community-acquired methicillin-resistant S. aureus infections pose a high risk for morbidity and mortality. Although the incidence of complex S. aureus infections is rising, new antimicrobial agents, including daptomycin and linezolid, are available as treatment. S. aureus is a common pathogen in skin, soft-tissue, catheter-related, bone, joint, pulmonary, and central nervous system infections. S. aureus bacteremias are particularly problematic because of the high incidence of associated complicated infections, including infective endocarditis. Adherence to precautions recommended by the Centers for Disease Control and Prevention, especially handwashing, is suboptimal. [ABSTRACT FROM AUTHOR]

Evaluates the effect of itraconazole prophylaxis for fungal infections in a randomized, placebo-controlled, double-blind study of HIV-positive persons. Efficacy of itraconazole antifungal drug in preventing histoplasmosis and cryptococcosis in patients; Factors associated with prophylaxis failure; Laboratory findings.

Ciprofloxacin, azlocillin, ceftizoxime, and amikacin were studied alone and in combination against six Enterobacteriaceae and six strains of in an infected chamber model in rabbits simulating a closed space infection. In-vivo results were compared with in-vitro tests of inhibition, killing and synergy. Ciprofloxacin was the most effective single agent, with efficacy against five of the six Enterobacteriaceae when used in low doses, and two of the six pseudomonads when used in high doses. The development of in-vitro resistance to ciprofloxacin was observed during therapy in strains which failed to be eradicated. Ciprofloxacin and azlocillin together was the most effective regimen, with efficacy against eleven of the twelve strains. Synergy, as determined by chequerboard testing, did not correlate with in-vivo outcome. Unlike mezlocillin, azlocillin, ceftizoxime or amikacin, MIC testing of ciprofloxacin was predictive of in-vivo success. [ABSTRACT FROM PUBLISHER]

The usual treatment of bacterial abscesses, except lung or tubo-ovarian abscesses, includes therapeutic drainage. Increasing evidence suggests that some abscesses respond to antimicrobial therapy without drainage. To study this issue, a MEDLINE search of the literature (1966–1994) was performed for cases of bacterial abscess in which treatment without definitive drainage was attempted. Four hundred sixty-five cases were identified. The most commonly involved organs were the liver, brain, and kidney. The success rate of antimicrobial therapy was 85.9%. Factors that predicted a less favorable outcome were abscess diameter of ⩾ 5 cm (odds ratio [OR] = 37.7; P = .0003), involvement of ⩾ 1 organism (OR = 5.2; P = .014), presence of gram-negative bacilli (OR = 3.4; P = .022), length of therapy of <4 weeks (OR = 49.1; P < .0001), and use of an aminoglycoside as the only active agent (OR = 11.8; P = .008). Many bacterial abscesses can be treated without drainage; abscess size, the organisms involved, and therapy utilized may influence outcome. [ABSTRACT FROM PUBLISHER]

Although septic shock may be the most common cause of distributive shock, to our knowledge, no studies have defined the likelihood and type of infection among patients with distributive shock. We performed a retrospective study of 100 consecutive patients who were admitted to a city-county hospital with hemodynamic evidence of distributive shock. Forty-nine of 100 patients with distributive shock had microbiological documentation of infection. Six patients had clinical evidence of infection without microbiological documentation. Forty-five patients had no microbiological or clinical evidence of infection. Among patients with microbiologically documented infections, the incidence of infection due to aerobic gram-positive cocci equaled the incidence of infection due to aerobic gram-negative bacilli. Clinical parameters, such as the criteria for the systemic inflammatory response syndrome, were not useful in distinguishing the group with infections from the group without infections. In conclusion, many patients with distributive shock do not have evidence of infection. [ABSTRACT FROM PUBLISHER]

Previous reports of infection due to Mycobacterium kansasii among patients infected with human immunodeficiency virus (HIV) have conflicted with regard to the significance of the isolate; the clinical, radiographic, and laboratory features of the disease; and the response to therapy. To clarify the spectrum of M. kansasii infection in this population, we conducted a retrospective study of 35 patients. Twenty-eight of these patients were believed to have disease due to M. kansasii, while the remaining seven patients were probably colonized with the organism. All but two patients presented with advanced HIV infection; the median CD4 cell count was 12/μL. Most patients with pulmonary disease presented with fever, cough, and dyspnea, but only eight of these 22 patients had radiographic findings of either pulmonary cavitation or predominantly upper-lobe disease. Ten patients had M. kansasii isolated from blood or bone marrow. The majority of patients with pulmonary or disseminated disease responded to therapy. However, 11 patients died either before mycobacterial infection was diagnosed or early in the course of treatment, and two had a relapse of infection during therapy. [ABSTRACT FROM PUBLISHER]

Reports on the effectiveness of multiple cerebral histoplasmomas with Itraconazole. Case of a woman with a history of type II diabetes mellitus; List of neurological signs and symptoms experienced by the woman; Administration of Itraconazole.

Staphylococcus aureus bacteremia (SAB) is a serious cause of bloodstream infection associated with significant morbidity and mortality. Complications include deep-seated foci of infection including infective endocarditis, device-associated infection, osteoarticular metastases, pleuropulmonary involvement, and recurrent infection. With the 30-day all-cause mortality being around 20%, a collaborative effort of early Infectious Diseases (ID) consultation and Antimicrobial Stewardship Program (ASP) involvement will show improved SAB outcomes and therapy optimization.1., (Copyright 2020 by the Missouri State Medical Association.)

Sexually transmitted infections have increased dramatically in the past 10 years. Rates are higher in Missouri than nationally, and higher in the large urban areas, in young adults, racial minority groups, among men having sex with men, and are associated with injection drug and methamphetamine use. Clinicians need to perform an appropriate sexual history and follow guidelines for screening and treatment. There is increasing concern for resistance among gonococcal isolates which limits future treatment options., (Copyright 2020 by the Missouri State Medical Association.)

Staphylococcus aureus bacteremia is a common disease with a high risk of mortality and complications. An increasing proportion of cases are methicillin-resistant S.aureus (MRSA), and methicillin-resistance is being observed from both community-acquired bacteremias and in healthcare-associated infections. The duration of bacteremia and transesophageal echocardiographic findings are useful in predicting the likelihood of complications including endocarditis. Therapy with vancomycin has been the mainstay in the treatment of MRSA bacteremias, but is associated with a long duration of bacteremia on therapy and relapses. Loss of susceptibility to vancomycin, due to thickened cell walls and through the acquisition of the vanA gene, has been described. Daptomycin is newly approved lipopeptide that is highly bactericidal against most strains of MRSA. In a randomized trial, daptomycin was demonstrated to be effective in the treatment of S. aureus bacteremia and right-sided endocarditis. However treatment failures associated with isolates with daptomycin non-susceptibility are reported, and there is a correlation between isolates with reduced vancomycin susceptibility and reduced daptomycin susceptibility. Daptomycin is a useful alternative to vancomycin in the therapy of MRSA bacteremia and endocarditis. However the appropriate role of daptomycin in optimizing therapy with MRSA bacteremia and endocarditis remains to be elucidated.

The murine D-galactosamine (D-gal) model of tumor necrosis factor alpha (TNF-alpha) hypersensitization was used as an initial tool to investigate the potential contribution of TNF-alpha to lethal intraperitoneal (i.p.) infection with Enterococcus faecalis. D-gal sensitized mice to lethal E. faecalis infection, whereas dexamethasone and neutralizing anti-TNF-alpha antibody protected D-gal-treated, E. faecalis-infected mice, implicating TNF-alpha in the lethal response to E. faecalis infection in D-gal-treated mice. Circulating TNF-alpha was undetectable for at least 8 h following i.p. E. faecalis infection, although low peritoneal levels of TNF-alpha were detected within 3 h, suggesting that localized TNF-alpha production contributed to the lethal response to E. faecalis infection in D-gal-treated mice. Although i.p. E. faecalis infection failed to induce a detectable systemic TNF-alpha response, circulating Interleukin-6 (IL-6) was detected within 3 h of infection. IL-6 was also detected in the peritoneum within an hour of infection, prior to the appearance of peritoneal TNF-alpha. In striking contrast to in vivo results, E. faecalis induced a potent and rapid TNF-alpha response from both mouse peritoneal macrophages and the RAW 264.7 cell line in vitro. This led us to hypothesize that TNF-alpha production in response to E. faecalis infection is suppressed by IL-6 in vivo. In vitro experiments demonstrated a statistically significant, but modest, inhibitory effect of IL-6 on TNF-alpha production by RAW cells stimulated with E. faecalis. Collectively, these data indicate that acute, lethal E. faecalis infection appears to induce an unusual cytokine response that differs in character from that previously described for most other gram-positive and gram-negative bacteria.

Bacteria survive within abscesses despite antimicrobial therapy, usually necessitating drainage. Our previous work showed that bacterial killing is diminished within the neutrophils of animals with abscesses. To further assess the role of neutrophils in Staphylococcus aureus survival and the poor activities of beta-lactams in abscesses, tissue cage abscess-bearing rats were given polymorphonuclear leukocyte (PMN)-depleting antibody prior to and several times following inoculation of the tissue cages with S. aureus. Cefazolin (300 mg/kg of body weight/day) was administered to all animals in appropriately divided doses. After 7 days of antimicrobial therapy, the 17 animals that received anti-PMN serum had significantly fewer abscess neutrophils than the 18 controls and fewer abscess bacteria (5.55 versus 3.79 log(10) CFU/ml [P = 0.04]) than the 18 controls. The data were consistent with the premise that cefazolin is more effective in abscesses depleted of neutrophils. To investigate further, S. aureus was incubated with rat peritoneal neutrophils; and bacterial cell membrane proteins were isolated, labeled with biotinylated ampicillin, separated by electrophoresis, blotted onto nitrocellulose, and stained for biotin reactivity. PBP 2 expression was consistently and significantly decreased after a brief, nonkilling PMN exposure. These experiments showed that PMN depletion enhanced the activity of cefazolin in the abscess milieu. Furthermore, altered bacterial cell wall cefazolin targets may be the mechanism by which the PMN diminishes antimicrobial activity, suggesting the importance of the staphylococcus-PMN interaction in the outcome of established infections.

Preview Infection of bone remains difficult to treat, despite recent advances in antimicrobial therapy and refinements in surgical technique. To add to the challenge, studies have been inconclusive in establishing the best method of obtaining a culture specimen, comparing the effectiveness of one drug regimen versus another, and determining the proper duration of antibiotic therapy. Dr Bamberger summarizes his experience with hematogenous osteomyelitis and osteomyelitis secondary to a contiguous focus of infection.