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He X, Tiballi RN, Zarins LT, Bradley SF, Sangeorzan JA, Kauffman CA. Azole resistance in oropharyngeal Candida albicans strains isolated from patients infected with human immunodeficiency virus. Antimicrob Agents Chemother 1994; 38:2495-7. [PMID: 7840596 PMCID: PMC284772 DOI: 10.1128/aac.38.10.2495] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
For 212 oropharyngeal isolates of Candida albicans, the fluconazole MICs for 50 and 90% of strains tested were 0.5 and 16 micrograms/ml, respectively, and those of itraconazole were 0.05 and 0.2 micrograms/ml, respectively. Of 16 isolates for which fluconazole MICs were > 64 micrograms/ml, itraconazole MICs for 14 were < or = 0.8 micrograms/ml and for 2 were > 6.4 micrograms/ml. Most fluconazole-resistant strains remained susceptible to itraconazole; whether itraconazole will prove effective for refractory thrush remains to be shown.
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Terpenning MS, Bradley SF, Wan JY, Chenoweth CE, Jorgensen KA, Kauffman CA. Colonization and infection with antibiotic-resistant bacteria in a long-term care facility. J Am Geriatr Soc 1994; 42:1062-9. [PMID: 7930330 DOI: 10.1111/j.1532-5415.1994.tb06210.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To assess colonization and infection with methicillin-resistant Staphylococcus aureus (MRSA), high-level gentamicin-resistant enterococci (R-ENT) and gentamicin and/or ceftriaxone-resistant Gram-negative bacilli (R-GNB) and the factors that are associated with colonization and infection with these organisms. DESIGN Monthly surveillance for colonization and infection over a period of 2 years. In the second year, an intervention to decrease MRSA colonization by the use of mupirocin ointment was carried out. SETTING Long-term care facility attached to an acute care Veterans Affairs Medical Center. PATIENTS A total of 551 patients in the facility were followed for a period of 2 years. MEASUREMENTS Colonization and infection rates with MRSA, R-ENT, and R-GNB. Analysis of risk factors associated with colonization and infection with these three groups of organisms. MAIN RESULTS In the first year, colonization rates were highest for MRSA (22.7 +/- 1% patients colonized each month) and R-ENT (20.2 +/- 1%) and lower for R-GNB (12.6 +/- 1%). After introduction of decolonization of nares and wounds with mupirocin, the rate of MRSA colonization fell significantly to 11.5 +/- 1.8%, but rates remained unchanged for R-ENT and R-GNB. Risk factors for MRSA colonization included the presence of wounds and decubitus ulcers. For R-ENT, the presence of wounds, renal failure, intermittent urethral catheterization, low serum albumin, and poor functional level were significant. For R-GNB, intermittent urethral catheterization, chronic renal disease, inflammatory bowel disease, presence of wounds, and prior pneumonia were significantly associated with colonization. Overall, of infections caused by known organisms, 49.6% were due to MRSA, R-ENT, or R-GNB, and 50.4% were due to susceptible organisms. Infections were more commonly due to R-GNB (21.1% of all infections) than to R-ENT (8.3%) or MRSA (4.6%). The most common infections were urinary tract infections (42.9% of all infections) and skin and soft tissue infections (31.9% of all infections). Risk factors for MRSA infections were diabetes mellitus and peripheral vascular disease, for R-GNB infections were intermittent urethral catheterization and indwelling urethral catheters, and no one factor was associated with R-ENT infection. CONCLUSIONS In our long-term care facility, colonization with resistant MRSA and R-ENT was more common than R-GNB, but infections were more often due to R-GNB than R-ENT and MRSA. Several host factors, which potentially could be modified in order to prevent infections, emerged as important in colonization and infection with these antibiotic-resistant organisms.
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Harrison MS, Simonte SJ, Kauffman CA. Trimethoprim-induced aseptic meningitis in a patient with AIDS: case report and review. Clin Infect Dis 1994; 19:431-4. [PMID: 7811861 DOI: 10.1093/clinids/19.3.431] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
We report the case of a 41-year-old man infected with human immunodeficiency virus who had two episodes of aseptic meningitis that occurred 2 weeks apart; the first was associated with ingestion of trimethoprim-sulfamethoxazole (TMP-SMZ) and the second was associated with ingestion of TMP alone. Onset of fever, headache, and flushing was abrupt, followed by somnolence, hearing loss, and aphasia. Analysis of the CSF showed pleocytosis and an elevated protein level. The findings resolved within 48 hours after withdrawal of the drug. We also review 18 previously reported cases of TMP-SMZ- or TMP-induced meningitis, 17 of which occurred in women. In all of these cases, a similar abrupt onset and resolution were noted. Six of the 18 patients had collagen-vascular diseases. All but two of these patients had multiple recurrent episodes of meningitis before the diagnosis was made. We conclude that the diagnosis of TMP-SMZ- or TMP-induced meningitis should be considered when a patient receiving these drugs has recurrent episodes of aseptic meningitis.
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Abstract
In the 1960s and 1970s, amphotericin B was the only effective therapy for serious systemic endemic fungal infections due to Histoplasma capsulatum, Blastomyces dermatitidis, and Sporothrix schenckii. In the 1980s, ketoconazole was introduced as therapy for endemic mycoses; after this antifungal agent was introduced, some of these infections could be treated orally in an outpatient setting rather than intravenously in an inpatient setting. The 1990s have become the triazole era. It is now standard practice to treat nonmeningeal, non-life-threatening histoplasmosis and blastomycosis orally on an outpatient basis; the drug of choice for this treatment is itraconazole. Itraconazole also has proved useful as treatment for histoplasmosis in patients infected with human immunodeficiency virus. Although itraconazole has not yet been approved for the treatment of sporotrichosis, in preliminary studies it has been shown to be effective therapy not only for cutaneous and lymphocutaneous sporotrichosis but also for disseminated infection with S. schenckii.
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Denning DW, Lee JY, Hostetler JS, Pappas P, Kauffman CA, Dewsnup DH, Galgiani JN, Graybill JR, Sugar AM, Catanzaro A. NIAID Mycoses Study Group Multicenter Trial of Oral Itraconazole Therapy for Invasive Aspergillosis. Am J Med 1994; 97:135-44. [PMID: 8059779 DOI: 10.1016/0002-9343(94)90023-x] [Citation(s) in RCA: 312] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Invasive aspergillosis is the most common invasive mould infection and a major cause of mortality in immunocompromised patients. Response to amphotericin B, the only antifungal agent licensed in the United States for the treatment of aspergillosis, is suboptimal. METHODS A multicenter open study with strict entry criteria for invasive aspergillosis evaluated oral itraconazole (600 mg/d for 4 days followed by 400 mg/d) in patients with various underlying conditions. Response was based on clinical and radiologic criteria plus microbiology, histopathology, and autopsy data. Responses were categorized as complete, partial, or stable. Failure was categorized as an itraconazole failure or overall failure. RESULTS Our study population consisted of 76 evaluable patients. Therapy duration varied from 0.3 to 97 weeks (median 46). At the end of treatment, 30 (39%) patients had a complete or partial response, and 3 (4%) had a stable response, and in 20 patients (26%), the protocol therapy was discontinued early (at 0.6 to 54.3 weeks) because of a worsening clinical course or death due to aspergillosis (itraconazole failure). Twenty-three (30%) patients withdrew for other reasons including possible toxicity (7%) and death due to another cause but without resolution of aspergillosis (20%). Itraconazole failure rates varied widely according to site of disease and underlying disease group: 14% for pulmonary and tracheobronchial disease, 50% for sinus disease, 63% for central nervous system disease, and 44% for other sites; 7% in solid organ transplant, 29% in allogeneic bone marrow transplant patients, and 14% in those with prolonged granulocytopenia (median 19 days), 44% in AIDS patients, and 32% in other host groups. The relapse rates among those who completed therapy and those who discontinued early for possible toxicity were 12% and 40%, respectively; all were still immunosuppressed. CONCLUSION Oral itraconazole is a useful alternative therapy for invasive aspergillosis with response rates apparently comparable to amphotericin B. Relapse in immunocompromised patients may be a problem. Controlled trials are necessary to fully assess the role of itraconazole in the treatment of invasive aspergillosis.
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131
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Voice RA, Bradley SF, Sangeorzan JA, Kauffman CA. Chronic candidal meningitis: an uncommon manifestation of candidiasis. Clin Infect Dis 1994; 19:60-6. [PMID: 7948559 DOI: 10.1093/clinids/19.1.60] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Chronic meningitis is an uncommon manifestation of candidiasis. We present the case of an elderly woman who had symptoms such as headache, malaise, and fever for 8 months and was found to have Candida albicans meningitis, and we review 17 similar cases. An underlying illness or risk factor for candidiasis was present in only 13 (72%) of the 18 patients. Headache, fever, and nuchal rigidity were the predominant clinical findings. Analysis of CSF showed either mononuclear or neutrophilic pleocytosis, an elevated protein level, and a decreased level of glucose. Only 17% of CSF smears were positive, and only 44% of initial CSF cultures yielded Candida species. In four cases, Candida species grew only after special techniques were used; in three cases, CSF cultures remained negative. The overall mortality associated with candidal meningitis was 53%, but among 12 patients who were treated and followed, the rate was 33%. In addition to acute meningitis seen with disseminated infection, Candida species can cause chronic meningitis that mimics tuberculosis and the more common fungal meningitides, such as cryptococcosis.
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Boyce JM, Jackson MM, Pugliese G, Batt MD, Fleming D, Garner JS, Hartstein AI, Kauffman CA, Simmons M, Weinstein R. Methicillin-resistant Staphylococcus aureus (MRSA): a briefing for acute care hospitals and nursing facilities. The AHA Technical Panel on Infections Within Hospitals. Infect Control Hosp Epidemiol 1994; 15:105-15. [PMID: 8201231 DOI: 10.1086/646870] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Carver PL, Berardi RR, Knapp MJ, Rider JM, Kauffman CA, Bradley SF, Atassi M. In vivo interaction of ketoconazole and sucralfate in healthy volunteers. Antimicrob Agents Chemother 1994; 38:326-9. [PMID: 7910724 PMCID: PMC284448 DOI: 10.1128/aac.38.2.326] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Absorption of ketoconazole is impaired in subjects with an increased gastric pH due to administration of antacids, H2-receptor antagonists, proton pump inhibitors, or the presence of hypochlorhydria. Sucralfate could provide an attractive alternative in patients receiving ketoconazole who require therapy for acid-peptic disorders. Twelve healthy human volunteers were administered a single 400-mg oral dose of ketoconazole in each of three randomized treatment phases. In phase A, ketoconazole was administered orally with 240 ml of water. In phase B, ketoconazole and sucralfate (1.0 g) were administered simultaneously with 240 ml of water. In phase C, ketoconazole was administered with 240 ml of water 2 h after administration of sucralfate (1.0 g) orally with 240 ml of water. A 680-mg oral dose of glutamic acid hydrochloride was administered 10 min prior to and with each dose of ketoconazole, sucralfate, or ketoconazole plus sucralfate. Simultaneous administration of ketoconazole and sucralfate led to a significant reduction in the area under the concentration-time curve and maximal concentration of ketoconazole in serum (78.12 +/- 12.20 versus 59.32 +/- 13.61 micrograms.h/ml and 12.34 +/- 3.07 versus 8.92 +/- 2.57 micrograms/ml, respectively; P < 0.05). When ketoconazole was administered 2 h after sucralfate, the observed ketoconazole area under the concentration-time curve was not significantly decreased compared with that of ketoconazole alone. The time to maximal concentrations in serum and the ketoconazole elimination rate constant were not significantly different in any of the three treatment phases. In patients receiving concurrent administration of ketoconazole and sucralfate, doses should be separated by at least 2 h.
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Smith KY, Bradley SF, Kauffman CA. Fever of unknown origin in the elderly: lymphoma presenting as vertebral compression fractures. J Am Geriatr Soc 1994; 42:88-92. [PMID: 8277122 DOI: 10.1111/j.1532-5415.1994.tb06080.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
MESH Headings
- Aged
- Biopsy, Needle
- Diagnosis, Differential
- Fever of Unknown Origin/etiology
- Fractures, Spontaneous/diagnosis
- Fractures, Spontaneous/etiology
- Humans
- Lymphoma, B-Cell/complications
- Lymphoma, B-Cell/diagnosis
- Lymphoma, Large B-Cell, Diffuse/complications
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Spinal Fractures/diagnosis
- Spinal Fractures/etiology
- Spinal Neoplasms/complications
- Spinal Neoplasms/diagnosis
- Thoracic Vertebrae/injuries
- Tomography, X-Ray Computed
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Janssen DA, Zarins LT, Schaberg DR, Bradley SF, Terpenning MS, Kauffman CA. Detection and characterization of mupirocin resistance in Staphylococcus aureus. Antimicrob Agents Chemother 1993; 37:2003-6. [PMID: 8239621 PMCID: PMC188110 DOI: 10.1128/aac.37.9.2003] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Fourteen mupirocin-resistant Staphylococcus aureus strains were isolated over 18 months; 12 exhibited low-level resistance, while two showed high-level resistance. Highly mupirocin-resistant strains contained a large plasmid which transferred mupirocin resistance to other S. aureus strains and to Staphylococcus epidermidis. This plasmid and pAM899-1, a self-transferable gentamicin resistance plasmid, have molecular and biologic similarities.
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Sharkey-Mathis PK, Kauffman CA, Graybill JR, Stevens DA, Hostetler JS, Cloud G, Dismukes WE. Treatment of sporotrichosis with itraconazole. NIAID Mycoses Study Group. Am J Med 1993; 95:279-85. [PMID: 8396321 DOI: 10.1016/0002-9343(93)90280-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE To describe the clinical presentation and outcomes of treatment with itraconazole in patients with sporotrichosis. METHODS A culture for Sporothrix schenckii or compatible histopathology was required for inclusion in the study. Patients with both cutaneous and systemic sporotrichosis were treated. Patients received from 100 to 600 mg of itraconazole daily for 3 to 18 months. Patients were classified as responders or nonresponders. Responders were further classified as remaining on treatment, relapsed, or free of disease. Nonresponders included patients who failed to respond or progressed during treatment with itraconazole. RESULTS Twenty-seven patients (mean age: 53 years) were treated with 30 courses of itraconazole. Diabetes mellitus and alcoholism were present in eight and seven patients, respectively. Sites of involvement included lymphocutaneous alone in 9 patients, articular/osseous in 15 (multifocal in 3), and lung in 3. Prior therapy was unsuccessful in 11 patients. Among the 30 courses, there were 25 responders and 5 nonresponders. All 5 nonresponders received at least 200 mg daily of itraconazole for durations that ranged from 6 to 18 months. Of the 25 responders, 7 relapsed 1 to 7 months after treatment durations of 6 to 18 months. Of the 7 who relapsed, 2 are responding to a second course. One responder was lost to follow-up after 10 months of treatment with itraconazole. Of the remaining 17 responders, 3 remain on treatment, and 14 are free of disease over follow-up durations of 6 to 42 months (mean: 17.6 months). Itraconazole was well tolerated with few side effects noted. CONCLUSIONS These results document the efficacy of itraconazole in the treatment of cutaneous and systemic sporotrichosis.
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Kauffman CA, Terpenning MS, He X, Zarins LT, Ramsey MA, Jorgensen KA, Sottile WS, Bradley SF. Attempts to eradicate methicillin-resistant Staphylococcus aureus from a long-term-care facility with the use of mupirocin ointment. Am J Med 1993; 94:371-8. [PMID: 8475930 DOI: 10.1016/0002-9343(93)90147-h] [Citation(s) in RCA: 134] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE To assess the impact of the use of mupirocin ointment on colonization, transmission, and infection with methicillin-resistant Staphylococcus aureus (MRSA) in a long-term-care facility. PATIENTS AND METHODS All 321 residents of a Veterans Affairs long-term-care facility from June 1990 through June 1991 were studied for MRSA colonization and infection. MRSA-colonized patients received mupirocin ointment to nares in the first 7 months and to nares and wounds in the second 5 months. The effect of mupirocin use on MRSA colonization and infection was monitored. All S. aureus strains isolated were tested for the development of resistance to mupirocin. RESULTS A total of 65 patients colonized with MRSA received mupirocin ointment. Mupirocin rapidly eliminated MRSA at the sites treated in most patients by the end of 1 week. Weekly maintenance mupirocin was not adequate to prevent recurrences--40% of patients had recurrence of MRSA. Overall, MRSA colonization in the facility, which was 22.7% +/- 1% prior to the use of mupirocin, did not change when mupirocin was used in nares only (22.2% +/- 2.1%), but did decrease to 11.5% +/- 1.8% when mupirocin was used in nares and wounds. Although colonization decreased, roommate-to-roommate transmission and MRSA infection rates, low to begin with, did not change when mupirocin was used. Mupirocin-resistant MRSA strains were isolated in 10.8% of patients. CONCLUSIONS Mupirocin ointment is effective at decreasing colonization with MRSA. However, constant surveillance was required to identify patients colonized at admission or experiencing recurrence of MRSA during maintenance treatment. Long-term use of mupirocin selected for mupirocin-resistant MRSA strains. Mupirocin should be saved for use in outbreak situations, and not used over the long term in facilities with endemic MRSA colonization.
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Mulligan ME, Murray-Leisure KA, Ribner BS, Standiford HC, John JF, Korvick JA, Kauffman CA, Yu VL. Methicillin-resistant Staphylococcus aureus: a consensus review of the microbiology, pathogenesis, and epidemiology with implications for prevention and management. Am J Med 1993; 94:313-28. [PMID: 8452155 DOI: 10.1016/0002-9343(93)90063-u] [Citation(s) in RCA: 464] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) has become a major nosocomial pathogen in community hospitals, long-term-care facilities, and tertiary care hospitals. The basic mechanism of resistance is alteration in penicillin-binding proteins of the organism. Methods for isolation by culture and typing of the organism are reviewed. MRSA colonization precedes infection. A major reservoir is the anterior nares. MRSA is usually introduced into an institution by a colonized or infected patient or health care worker. The principal mode of transmission is via the transiently colonized hands of hospital personnel. Indications for antibiotic therapy for eradication of colonization and treatment of infection are reviewed. Infection control guidelines and discharge policy are presented in detail for acute-care hospitals, intensive care and burn units, outpatient settings, and long-term-care facilities. Recommendations for handling an outbreak, surveillance, and culturing of patients are presented based on the known epidemiology.
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Kauffman CA, Bradley SF, Vine AK. Candida endophthalmitis associated with intraocular lens implantation: efficacy of fluconazole therapy. Mycoses 1993; 36:13-7. [PMID: 8316256 DOI: 10.1111/j.1439-0507.1993.tb00681.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Four patients with Candida parapsilosis endophthalmitis following intraocular lens implantation were treated with oral fluconazole. All had failed prior therapy with intravitreal amphotericin B. The only patient who had the lens implant removed was cured after treatment with fluconazole for one year. Three patients who did not have the lens implant removed had resolution of symptoms and return of visual acuity towards normal during the year they were on fluconazole. However, five months after therapy had been stopped, all three had decreasing visual acuity, and in two, culture of vitreous fluid yielded C. parapsilosis. Fluconazole may be effective for treatment of endophthalmitis associated with an intraocular lens implant, but only when the implant is removed also.
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Schaberg DR, Dillon WI, Terpenning MS, Robinson KA, Bradley SF, Kauffman CA. Increasing resistance of enterococci to ciprofloxacin. Antimicrob Agents Chemother 1992; 36:2533-5. [PMID: 1489199 PMCID: PMC284368 DOI: 10.1128/aac.36.11.2533] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We determined that resistance to ciprofloxacin has emerged in enterococci over the last 5 years in our hospital, mainly in strains demonstrating the phenotype of high-level gentamicin resistance. All high-level-gentamicin-resistant isolates from 1985 and 1986 were susceptible, whereas 24% of isolates from 1989 and 1990 were resistant to ciprofloxacin. Plasmid and genomic DNA typing showed at least six unique strains exhibiting resistance, but one type accounted for 80% of recent resistant isolates, suggesting a role for cross infection in the emergence of resistance.
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141
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Kauffman CA. Fungal infections. Clin Geriatr Med 1992; 8:777-91. [PMID: 1423134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Increased travel and outdoor leisure activities place the elderly individual at risk for infection with the endemic mycoses, histoplasmosis, blastomycosis, coccidioidomycoses, and sporotrichosis. Elderly patients who are immunosuppressed are at risk for infection with the opportunistic fungi such as Candida and Aspergillus. In this article, the clinical manifestations and the approach to diagnosis are discussed. The use of antifungal agents that are currently available to treat severe fungal infections also are reviewed.
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142
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Chenoweth CE, Judd WJ, Steiner EA, Kauffman CA. Cefotetan-induced immune hemolytic anemia. Clin Infect Dis 1992; 15:863-5. [PMID: 1445986 DOI: 10.1093/clind/15.5.863] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Immune hemolytic anemia due to a drug-adsorption mechanism has been described primarily in patients receiving penicillins and first-generation cephalosporins. We describe a patient who developed anemia while receiving intravenous cefotetan. Cefotetan-dependent antibodies were detected in the patient's serum and in an eluate prepared from his red blood cells. The eluate also reacted weakly with red blood cells in the absence of cefotetan, suggesting the concomitant formation of warm-reactive autoantibodies. These observations, in conjunction with clinical and laboratory evidence of extravascular hemolysis, are consistent with drug-induced hemolytic anemia, possibly involving both drug-adsorption and autoantibody formation mechanisms. This case emphasizes the need for increased awareness of hemolytic reactions to all cephalosporins.
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Braun DK, Kauffman CA. Rhodotorula fungaemia: a life-threatening complication of indwelling central venous catheters. Mycoses 1992; 35:305-8. [PMID: 1302803 DOI: 10.1111/j.1439-0507.1992.tb00882.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A 30-year-old woman receiving total parenteral nutrition via an indwelling central venous catheter for an intestinal motility disorder developed fever, tachycardia, tachypnea, and hypotension. Multiple blood cultures drawn through the catheter prior to these events, as well as a peripheral blood culture obtained earlier, grew the red yeast Rhodotorula rubra. The patient was critically ill for over one month but eventually recovered with therapy including the systemic antifungal agents amphotericin B and flucytosine and removal of the catheter. Although Rhodotorula has generally been regarded as having low pathogenicity, this case emphasizes the serious nature of Rhodotorula sepsis and suggests the need for both systemic antifungal therapy and removal of a colonized indwelling catheter.
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Dismukes WE, Bradsher RW, Cloud GC, Kauffman CA, Chapman SW, George RB, Stevens DA, Girard WM, Saag MS, Bowles-Patton C. Itraconazole therapy for blastomycosis and histoplasmosis. NIAID Mycoses Study Group. Am J Med 1992; 93:489-97. [PMID: 1332471 DOI: 10.1016/0002-9343(92)90575-v] [Citation(s) in RCA: 228] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To assess the efficacy and toxicity of orally administered itraconazole in the treatment of nonmeningeal, nonlife-threatening forms of blastomycosis and histoplasmosis. DESIGN Prospective, nonrandomized, open trial. SETTING Multicenter trial at 14 university referral centers. PATIENTS Eighty-five patients with culture or histopathologic evidence of blastomycosis (48 patients) or histoplasmosis (37 patients). Patients receiving other systemic antifungal therapy were excluded. INTERVENTIONS Itraconazole was administered orally at doses of 200 to 400 mg/d. Patients in whom treatment was considered a success were treated for a median duration of 6.2 months (blastomycosis) and 9.0 months (histoplasmosis). Disease activity was assessed at baseline; drug efficacy and toxicity were evaluated at monthly intervals during therapy, and efficacy was evaluated at regular follow-up visits after completion of therapy. The median duration of posttreatment evaluation for successfully treated patients was 11.9 months (blastomycosis) and 12.1 months (histoplasmosis). MEASUREMENTS AND MAIN RESULTS Among the 48 patients with blastomycosis, success was documented in 43 (90%). The success rate for patients treated for more than 2 months was 95% (38 of 40). Among the 37 patients with histoplasmosis, success was documented in 30 (81%). The success rate for patients treated for more than 2 months was 86% (30 of 35). All patients with histoplasmosis in whom treatment failed had chronic cavitary pulmonary disease. Toxicity was minor; only 25 (29%) patients experienced any side effects, and itraconazole toxicity necessitated stopping therapy in only 1 patient. CONCLUSIONS Itraconazole is a highly effective therapy for nonmeningeal, nonlife-threatening blastomycosis and histoplasmosis. The drug is associated with minimal toxicity.
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Neitzel S, Kauffman CA. Fever of unknown origin after Angelchik antireflux prosthesis implantation. Clin Infect Dis 1992; 15:528-9. [PMID: 1520803 DOI: 10.1093/clind/15.3.528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The Angelchik device is a silicone collar placed at the gastroesophageal junction for preventing reflux. Many complications associated with the use of this device have been reported, including disruption, migration, and erosion into the gastrointestinal tract. We report another complication of the device, that of abscess formation presenting as fever of unknown origin. This complication emphasizes the need for careful investigation of any implanted foreign body in the evaluation of a patient who has fever of unknown origin.
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Triesenberg SN, Clark NM, Kauffman CA. Group B streptococcal prosthetic joint infection following sigmoidoscopy. Clin Infect Dis 1992; 15:374-5. [PMID: 1520775 DOI: 10.1093/clinids/15.2.374-a] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Crump JR, Elner SG, Elner VM, Kauffman CA. Cryptococcal endophthalmitis: case report and review. Clin Infect Dis 1992; 14:1069-73. [PMID: 1600008 DOI: 10.1093/clinids/14.5.1069] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Cryptococcus neoformans is an opportunistic fungus with a predilection for infecting the meninges. Ocular sequelae of cryptococcal infections of the CNS usually include cranial nerve palsies or papilledema secondary to increased intracranial pressure. Intraocular cryptococcosis occurs less frequently, and over the last 23 years, only 27 cases have been reported, including the case presented here. Intraocular infection was most often manifested by chorioretinal lesions and vitritis. Underlying diseases were detected in only 11 (41%) of the 27 patients. Of note, ocular lesions preceded symptomatic meningitis in six (27%) of 22 patients with CNS involvement. For seven patients, the diagnosis was made by histologic examination of specimens of aqueous or vitreous humor; for another eight patients, the diagnosis was made after enucleation or at autopsy. Ocular involvement frequently led to severe visual loss; return of vision to normal was unusual. Early recognition and treatment may improve outcome for these patients.
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Bradley SF, Terpenning MS, Ramsey MA, Zarins LT, Jorgensen KA, Sottile WS, Schaberg DR, Kauffman CA. Methicillin-resistant Staphylococcus aureus: colonization and infection in a long-term care facility. Ann Intern Med 1991; 115:417-22. [PMID: 1908198 DOI: 10.7326/0003-4819-115-6-417] [Citation(s) in RCA: 224] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To assess methicillin-resistant Staphylococcus aureus (MRSA) colonization, transmission, and infection over a 1-year period in a long-term care facility with endemic MRSA. DESIGN Monthly surveillance for MRSA colonization of nares, perineum, rectum, and wounds. SETTING Long-term care facility attached to an acute care Veterans Affairs medical center. PATIENTS All 341 patients in the facility had monthly surveillance cultures for 1 year. OUTCOME MEASUREMENTS Colonization and infection with MRSA. MAIN RESULTS The monthly MRSA colonization rate was 23% +/- 1.0%; colonization occurred most commonly in the nares and wounds. Poor functional status was associated with MRSA colonization. Most patients (65%) never acquired MRSA; 25% of patients were already colonized at admission to the facility or at the start of the study, and only 10% of newly admitted patients acquired MRSA while in the facility. These latter patients acquired several different strains in a pattern of acquisition similar to that generally seen within the facility. In the course of 1 year, only nine patients who acquired MRSA had a roommate with the same phage type; no clustering was evident, and none of these patients developed infection. Nine other patients (3%) developed MRSA infection; five of these patients required hospitalization, but none died as a result of infection. CONCLUSIONS In the long-term care facility in which our study took place, MRSA was endemic, and the infection rate was low. In such settings, the cost effectiveness of aggressive management of MRSA (widespread screening for MRSA and eradication with antimicrobial agents) needs to be assessed.
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Abstract
PURPOSE To determine if fluconazole is effective treatment for hepatosplenic candidiasis that has not resolved with amphotericin B and flucytosine treatment. PATIENTS AND METHODS Six patients (ages 3 to 44) with acute leukemia and hepatosplenic candidiasis who did not respond to prior antifungal therapy were treated with fluconazole. RESULTS All six patients had fever and three had nausea and vomiting; computed tomographic (CT) scan showed lucencies in the liver in six, lucencies in the spleen in five, and lucencies in the kidneys in three. Prior therapy with 1.6 to 4 g of amphotericin B in the five adults and 526 mg of amphotericin B in the child (with the addition of flucytosine in four) failed to improve clinical symptoms or lucencies in the liver, spleen, and kidneys seen on CT scan. Fluconazole was given at a dose of 200 to 400 mg daily (70 to 100 mg in the child) for 2 to 14 months. All patients had resolution of fever and other symptoms in 2 to 8 weeks. Improvement of the lesions noted on CT scan was seen in 4 to 8 weeks in all patients. Total resolution of lesions noted on CT scan occurred by 4 weeks in two patients, but took 4 to 5 months for three patients and 13 months for one patient. Three patients had relapse of their acute leukemia and two died, presumably cured of their candidiasis. Two patients underwent successful bone marrow transplantation without relapse of their candidiasis. CONCLUSION Fluconazole appears to be useful in the treatment of hepatosplenic candidiasis that has not resolved with amphotericin B and flucytosine therapy.
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