Monobactam and aminoglycoside combination therapy against metallo-beta-lactamase-producing multidrug-resistant Pseudomonas aeruginosa screened using a 'break-point checkerboard plate'

Metallo-beta-lactamase-producing multidrug-resistant Pseudomonas aeruginosa (MDR P. aeruginosa) is a cause of life-threatening infections. With parenteral colistin not available in Japan, we treated MDR P. aeruginosa sepsis with monobactam and aminoglycoside combination therapy, with screening using a 'break-point checkerboard plate'.

Infective endocarditis complicated with splenic abscess successfully treated with splenectomy followed by double valve replacement

Splenic abscess (SA) is a rare complication of infective endocarditis (IE). A successful outcome lies with a choice between medical and surgical treatments. However, there is still insufficient evidence in the decision-making process. Our patient was a 73-year-old male who complained mainly of fever and general fatigue. An echocardiography showed vegetation of 10 mm in diameter and severe mitral and aortic regurgitation and a diagnosis was made of IE. Because of a recent brain embolism, we decided to treat him initially with medical therapy. Antibiotics were effective, but on the 28th day after starting treatment, he complained of left upper abdominal pain. An abdominal computed tomography scan showed SA. The administration of vancomycin did not improve the condition. We decided that he should undergo surgical treatment. A splenectomy was performed and 9 days after the splenectomy, the mitral and aortic valves were successfully replaced. There is still no clear-cut evidence to support the order of surgical interventions. Indeed, the current guidelines, which recommend that splenectomy is to be performed first, are not supported by strong evidence. The present case report showed that splenectomy before valve surgery successfully treated the patient.

Comparison of clinical and radiological features of pneumocystis pneumonia between malignancy cases and acquired immunodeficiency syndrome cases: a multicenter study

BACKGROUND

The clinical features of pneumocystis pneumonia (PCP) differ according to the predisposing factors responsible for immunosuppression. Although PCP in patients with acquired immunodeficiency syndrome (AIDS) has been extensively described, its characteristics in non-AIDS patients, such as those with malignancies, are not thoroughly documented.

STUDY OBJECTIVE

To characterize and compare the clinical and imaging features of PCP in patients with malignancies with those in AIDS patients.

DESIGN

A multi-center retrospective study.

PATIENTS AND MEASUREMENTS

We evaluated the clinical and radiological features of PCP in 21 patients with malignancies and in 17 with AIDS. Clinical presentation, serum markers, oxygenation, CT findings, and outcome were examined.

RESULTS

The patients with malignancies showed shorter durations of symptoms before PCP was diagnosed. The levels of serum markers and the oxygenation index did not differ. CT showed diffuse or widespread ground-glass opacity (GGO) in all of the patients evaluated. None of the AIDS patients demonstrated consolidation, whereas half of the patients with malignancy showed consolidation along with GGO. The extent of GGO scored on CT images was significantly greater in the AIDS patients. No correlation was observed between the CT findings and other clinical parameters. All of the AIDS patients recovered from PCP, whereas six patients with malignancies died within a month after the onset of PCP.

CONCLUSION

The characteristics of the CT images differed between the patient groups with different underlying disorders, although it remains to be determined whether CT findings are associated with other clinical features or are predictive of the outcome of PCP.

High incidence of haemophagocytic syndrome following umbilical cord blood transplantation for adults

Umbilical cord blood transplantation (CBT) is widely accepted, but one critical issue for adult patients is a low engraftment rate, of which one cause is haemophagocytic syndrome (HPS). We aimed to identify the contribution of HPS to engraftment failure after CBT, following preparative regimens containing fludarabine phosphate, in 119 patients (median age, 55 years; range; 17-69 years) with haematological diseases. Graft-versus-host disease prophylaxis comprised continuous infusion of a calcineurin inhibitor with or without mycophenolate mofetil. Of the 119 patients, 20 developed HPS within a median of 15 d (cumulative incidence; 16.8%) and 17 of them did so before engraftment. Donor-dominant chimaerism was confirmed in 16 of 18 evaluable patients with HPS. Despite aggressive interventions including corticosteroid, ciclosporin, high-dose immunoglobulin and/or etoposide, engraftment failed in 14 of 18 patients. Of these 14 patients, four received second rescue transplantation and all resulted in successful engraftment. Overall survival rates significantly differed between patients with and without HPS (15.0% vs. 35.4%; P < 0.01). Univariate and multivariate analysis identified having fewer infused CD34(+) cells as a significant risk factor for the development of HPS (P = 0.01 and 0.006, respectively). We concluded that engraftment failure closely correlated with HPS in our cohort, which negatively impacted overall survival after CBT.

[Case of sepsis caused by multidrug-resistant neutropenic-phase Pseudomonas aeruginosa treated successfully with antibiotic combination therapy]

Multidrug-resistant Pseudomonas aeruginosa (MDRP), defined as Pseudomonas aeruginosa resistant to aminoglycosides, carbapenems, and fluoroquinolones, has emerged as an increasingly problematic cause of hospital-acquired infection. With parenteral colistin unavailable in Japan, effective antimicrobial options are severely limited. We report a case of MDRP bacteremia successfully treated with antibiotic combination therapy screened by a 'Break-point Checkerboard Plate'. A 54-year-old man with malignant lymphoma who became febrile 9 days after a recent course of chemotherapy had a neutrophil count of 176/microL. Treatment with meropenem and vancomycin was ineffective and high fever persisted. Methicillin-resistant Staphylococcus aureus (MRSA) and MDRP were isolated from blood culture and combination therapy with aztreonam and amikacin was selected for MDRP based on 'Break-point Checkerboard Plate' results. Linezolid was used for MRSA. The patient recovered successfully from MDRP and MRSA sepsis.