Faculty Bibliography

The MICs and MBCs of ciprofloxacin were determined for clinical isolates of antibiotic-resistant aerobic bacteria. Decreased susceptibility to ciprofloxacin of cefotaxime- and amikacin-resistant Serratia marcescens and amikacin-resistant Pseudomonas aeruginosa strains were noted. The data suggest that ciprofloxacin susceptibility should be carefully monitored in treating patients with hospital-acquired bacterial infections

The synergistic bactericidal activity of netilmicin in combination with penicillins was compared with that of gentamicin and streptomycin against 16 clinical isolates of enterococci. In a macrodilution chessboard assay against multiple combinations of penicillin, gentamicin and netilmicin, bactericidal activity uniformly occurred at two- to four-fold lower concentrations of penicillin + netilmicin than with penicillin + gentamicin. With four strains, penicillin + netilmicin produced up to ten-fold greater killing than penicillin + gentamicin after 6 h of incubation. With one strain, 3 X log10 greater killing occurred with netilmicin after 24 h. Netilmicin was two- to four-fold more active than gentamicin when combined with penicillinase-resistant penicillins. The bactericidal activity of netilmicin against enterococci is equal to or greater than that of gentamicin, either alone or when combined with penicillins

Between 1 January 1981 and 1 December 1984, 34 of 396 patients with the acquired immunodeficiency syndrome (AIDS) developed cryptococcal infections. Twenty-six cases are reviewed. Twenty-two patients had brain or meningeal disease; the others had pulmonary disease (2 patients), pericarditis (1 patient), and antigenemia (1 patient). During treatment, 3 patients died of cryptococcosis and 3 died of other causes. Fifteen patients were followed for more than 6 weeks after treatment. Of 8 patients who received no additional amphotericin B, 4 had relapses and died of cryptococcosis within 6 months, 3 died of other causes, and 1 survived. Of 7 patients who received maintenance therapy with amphotericin B, none had relapses, 3 died of other causes, and 4 survived. Our data suggest that maintenance therapy with amphotericin may be needed to prevent relapse in patients with AIDS

Ten of 294 isolates of Streptococcus pneumoniae from patients enrolled in a Veterans Administration Cooperative Studies Program trial of pneumococcal vaccine efficacy were moderately resistant or resistant to penicillin. Nine of these organisms were serotype 19A isolated from patients at the Brooklyn (New York) V.A. Medical Center over an 18-month period (March 1983-November 1984). The minimal inhibitory concentration of penicillin for these pneumococci ranged from 1.0 to 2.0 micrograms/ml by the agar dilution technique and from 4.0 to 8.0 micrograms/ml by tube dilution. These organisms were resistant also to other beta-lactam antibiotics and to tetracycline, chloramphenicol, and trimethoprim-sulfamethoxazole. They were sensitive to erythromycin, clindamycin, vancomycin, and rifampin. The epidemiological source of these isolates was not discovered. However, it is possible that a focus of multiple antibiotic-resistant serotype 19A S. pneumoniae is present in Brooklyn

Three patients with severe Pneumocystis carinii pneumonia and acquired immunodeficiency syndrome, not responding to specific therapy with trimethoprim/sulfamethoxazole, were treated with a 24-hour course of high-dose methylprednisolone. Rapid improvements in the clinical status and the chest X-rays were detected. In two of the patients, in whom lung biopsy was performed before initiation of corticosteroids, an intense interstitial mononuclear cell infiltrate was seen. In the one patient who had lung biopsy after corticosteroid therapy, a scanty amount of mononuclear cells was demonstrated in the interstitium. Our experience suggests that corticosteroids may be useful as adjunctive agents in the treatment of severe P. carinii pneumonia not responding to specific anti-Pneumocystis therapy. This may be a result of inhibition of mononuclear cell accumulation within the lung by the steroid therapy

The synergistic activity of cefotaxime and amikacin against 21 highly resistant Pseudomonas aeruginosa and Serratia marcescens isolates was evaluated in-vitro by the checkerboard tube dilution method and in-vivo in five patients with serious infections caused by these organisms. All isolates were resistant to gentamicin, tobramycin, amikacin, and cefotaxime. Synergy was observed in 90% of isolates and occurred when the MIC of amikacin was less than 256 mg/l and of cefotaxime less than 1024 mg/l. A clinical response occurred in 100% and bacteriological cure in 80% of patients. Our results demonstrate a high degree of synergism between amikacin and cefotaxime in-vitro and clinical efficacy in the treatment of infections due to multiply-resistant Pseudomonas and Serratia species

The incidence of amikacin resistance among gram-negative bacilli isolated at the New York V.A. Medical Center increased from 2.0% to greater than 7% during an 18-month period from January 1980 to July 1981. This increase coincided with a threefold increase in amikacin use at this institution. The amikacin-resistant (AKR) isolates most frequently recovered in 1981 were species of Klebsiella, Serratia, and Pseudomonas. These organisms were recovered from multiple sites, including urine, sputum, wounds, blood, peritoneal fluid, and pleural fluid. The amikacin-modifying enzyme 6'-N-acetyltransferase was detected in 27 (67.5%) of 40 randomly selected AKR isolates. These data indicate that resistance to amikacin in this hospital is enzymatically mediated in most strains of AKR Klebsiella and Serratia and in about one-third of AKR strains of P. aeruginosa. This finding supports the conclusion that amikacin resistance is enhanced by the pressure of increased amikacin use

Five patients had Streptococcus pneumoniae infections among the 35 hospitalized with acquired immune deficiency syndrome (AIDS) at the New York Veterans Administration Medical Center between January 1, 1982, and June 30, 1983. Three of these patients had pneumococcal bacteremia and 2 had pneumonia without bacteremia. Twenty-seven bacteremic S. pneumoniae infections occurred among 5,143 patients without AIDS admitted to the Medical Service of this hospital during the same period. Thus, pneumococcal bacteremia was more likely to occur in patients with AIDS than in the general hospitalized population (x2 = 26, p = less than 0.001). Two of the bacteremic infections were caused by S. pneumoniae type 4. One of these occurred in a patient who had been inoculated with the 14 valent pneumococcal vaccine 5 months earlier. There were no significant differences in concentrations of radioimmunoassay antibody to type 4 pneumococcal polysaccharide in sequential serum samples collected from this patient, and opsonic titers to this organism were not detected. It is concluded that pneumococcal infections are very common among patients with AIDS, and may not be prevented by active immunoprophylaxis

In a prospective evaluation twenty patients with gram-negative bacillary meningitis were treated with moxalactam, either alone or in conjunction with other antibiotics. Of thirteen patients who received only moxalactam, eight recovered, one failed to respond, and five died of causes other than meningitis. Cultures of CSF were negative before death in each instance. Thirteen (65%) of 20 treated patients recovered. Reversible hypoprothrombinemia and bleeding occurred secondary to moxalactam therapy in one patient. The mortality from gram-negative bacillary meningitis remains high owing to the incidence of associated underlying disease. Moxalactam brings about bacteriologic control in a large proportion of patients who are infected with highly sensitive gram-negative enteric bacilli

A case is described in which Klebsiella pneumoniae urosepsis associated with acute myocardial infarction resulted in myocardial abscess and papillary muscle rupture. The diagnosis was made during surgery for mitral valve replacement. The patient improved after therapy with cefotaxime; however, cardiac rupture occurred on the sixth postoperative day. The pathogenesis of myocardial abscess and the use of non-invasive techniques for diagnosis are discussed