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Between 1979 and 1982, thirty-eight patients with chronic non-hematogenous osteomyelitis were treated by local débridements of the wound, prolonged parenteral administration of antibiotics, and an average of forty-eight once-a-day treatments with hyperbaric oxygen. Of these thirty-eight patients, thirty-four remained free of clinical signs of osteomyelitis for an average of thirty-four months (range, twenty-four to fifty-nine months) after this regimen of treatment. Only four of the thirty-eight patients had been free of clinical signs of osteomyelitis for as long as three months during the two years preceding this treatment. Three of the four failures of treatment were evident within one month after treatment. This method of treatment appears to prolong the infection-free interval of patients with chronic non-hematogenous osteomyelitis.

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A major common-source, foodborne epidemic of typhoid fever occurred in San Antonio, Tex, in the fall of 1981, involving 80 verified cases. We summarize the clinical course of our 34 patients who had a nonspecific symptom complex that included at the initial examination fever (32 patients, 93%), headache (19 patients, 57%), diarrhea (11 patients, 33%), and anorexia (ten patients, 30%). The most common initial diagnoses were urinary tract and upper respiratory tract infections. The subsequent isolation of Salmonella typhi from blood cultures was usually unexpected. Physical findings were different from two previous series originating in the United States. Hepatomegaly was noted in only 7% (two patients), splenomegaly was noted in 13% (four patients), and rose spots were noted in 5% (two patients) of the patients. Liver function test results, however, were abnormal in 32 (95%) of the 34 patients (mean SGOT, 155 IU/mL). Typhoid fever, as seen in this outbreak, was notable for its nonspecific and mild manifestation and uniformly favorable outcome.

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One hundred seventeen unselected women with symptoms of acute cystitis were randomized to groups for immediate therapy with one of the following four single-dose regimens: (1) 1 g of sulfisoxazole; (2) 2 g of sulfisoxazole; (3) a combination of trimethoprim, 160 mg, and sulfamethoxazole, 800 mg; and (4) a combination of trimethoprim, 320 mg, and sulfamethoxazole, 1,600 mg. Forty-one women were excluded, 13 did not return for follow-up, and 28 did not have significant bacteriuria in the pretherapy culture. Escherichia coli was isolated in 81% of infections. Antibacterial activity was significantly greater in urine collected during the 24 hours after therapy in those who received trimethoprim-sulfamethoxazole. However, overall cure varied from 85% to 95%, without any great differences between the regimens. The rate of cure of 69% in the 13 patients with presumptive evidence of renal infection (antibody-coated bacteria present) was significantly lower than the rate of cure of 95% in women without evidence of renal infection. Single-dose therapy with these regimens was safe and effective in adult women with symptoms of acute cystitis, regardless of the localization of the site of infection.

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Trimethoprim was used alone to treat urinary tract infections in 20 women who were unable to tolerate sulfonamides. Of ten acute symptomatic urinary tract infections, four were cured, three were not, and three cases could not be evaluated. Two other women received trimethoprim for suppression of infection complicating stag-horn calculi. The conditions of both patients improved clinically but the urine remained infected. Eight women treated prophylactically with low-dose trimethoprim for recurrent urinary tract infection accumulated a total of 16 patient-years of prophylaxis. During treatment, the incidence of infection was 0.56 per patient-year compared with 4.25 infections in the year preceding study. Adverse reactions occurred in eight of 20 patients and administration of the drug had to be stopped in five cases. Trimethoprim alone is effective for the treatment and prophylaxis of urinary tract infections, but may cause a high incidence of adverse reactions in patients known to be sensitive to sulfonamides.

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For a period of one year we identified all urinary isolates of Enterobacteriaceae resistant to either nalidixic acid (NA) or trimethoprim (TMP). Host and organism characteristics associated with the occurrence of 68 NA and 61 TMP-resistant isolates were compared with 61 matched antimicrobial-susceptible controls. Minimum inhibitory concentrations to NA and TMP were carried out on all isolates, Escherichia coli isolates were biotyped and TMP-sulfamethoxazole (SMX) synergy studies were performed on TMP-resistant isolates. Study patients were reviewed with regard to age, renal function, presence of structural urinary tract abnormality, history of antimicrobial treatment and persistence of study strains within the urinary tract. Resistance to both drugs was associated with prior treatment with the relevant antimicrobial and with underlying urinary tract abnormality. No association was noted between resistance and patient age or renal function. Once resistant organisms infected an abnormal urinary tract, they were able to persist almost indefinitely. Patients with persistent urinary infections associated with structural urinary tract abnormality account for most NA or TMP-resistant infections in our hospital and constitute an identifiable group in whom the therapeutic usefulness of these drugs is limited.

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The results of a prospective, randomized comparative study of the efficacy and toxicity of clindamycin, chloramphenicol, and ticarcillin in the treatment, concomitantly with gentamicin to ensure complete aerobic coverage, of 175 patients with serious mixed aerobic/anaerobic intraabdominal or female genital tract sepsis are reported. In the group with intraabdominal sepsis, 33 (79%) of 42 treated with clindamycin, 43 (81%) of 53 treated with chloramphenicol, and 35 (90%) of 39 treated with ticarcillin were cured. In the group with genital tract sepsis, 16 (94%) of 17 treated with clindamycin, 11 (100%) of 11 treated with chloramphenicol, and 12 (92%) of 13 treated with ticarcillin were cured. Diarrhea occurred most frequently in patients treated with clindamycin (P < 0.001), hematologic suppression occurred most frequently in patients treated with chloramphenicol (P < 0.01), and hypokalemia occurred most frequently in patients treated with ticarcillin (P < 0.01). Clindamycin, chloramphenicol, and ticarcillin, each in combination with gentamicin, are equally effective in therapy for intraabdominal or female genital tract sepsis.

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Introital colonization with Enterobacteriaceae is considered to be one of the principal predisposing factors to recurrent urinary tract infections (UTI) in adult females. One proposed mechanism allowing introital colonization in these patients is the absence of local cervicovaginal antibody. To test this hypothesis, we examined cervicovaginal washings from 22 patients with a history of recurrent UTI and 29 normal controls with no history of UTI for specific local antibody by using indirect immunofluorescence. No significant difference in antibody was found in these populations. Fourteen percent (3/22) of the patients had antibody to their introital Escherichia coli and 34% (10/29) of the controls had antibody to their fecal E. coli. Consequently, a sensitive radioimmunoassay technique was developed to detect cervicovaginal antibody. A solid phase was prepared by coupling to Sepharose 4B a pool of eight serogroups of E. coli which are frequently implicated in UTI. Serial dilutions of cervicovaginal washings were reacted with the solid phase, and the absorbed anti-E. coli antibodies were detected by the uptake of (125)I-labeled anti-human immunoglobulin G (IgG) or anti-human IgA. The antibody levels were quantitated by interpolation on a standard curve prepared by using immunospecifically purified human anti-E. coli antibodies. IgG and IgA levels were measured in washings from 10 colonized patients, 13 non-colonized patients, and 12 controls. There were no significant differences in IgG and IgA levels in cervicovaginal washings among the three groups. In these studies, introital colonization was not related to cervicovaginal antibody.

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Thirty-two women with recurrent urinary tract infections were treated after eradication of existing infections with a mixture of 40 mg of trimethoprim and 200 mg of sulfamethoxazole thrice weekly at bedtime for six months. Six preadolescents received one half this dose. During 21.3 cumulative patient-years of prophylaxis, one infection due to Streptococcus faecalis and one due to a sulfamthoxazole-and trimethoprim-sensitive Escherichia coli occurred--an infection incidence of 0.1 per patient-year. During prophylaxis, 61 of 72 periurethral cultures and 24 of 51 anal canal cultures failed to yield Enterobacteriaceae. One patient had transient colonization with a trimethoprim-resistant E coli during prophylaxis. Twenty-one patients had recurrent infection within six months of discontinuation of prophylaxis, with a mean time to recurrence of 2.6 months. One infection recurred 26 weeks following prophylaxis with a Proteus mirabilis. Thrice-weekly trimethoprim-sulfamethoxazole therapy was effective for prophylaxis of recurrent urinary tract infections and did not predispose to colonization or infection with trimethoprim-resistant Enterobacteriaceae.

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A nine-test system using multiple-inoculation agar plates for biotyping of Escherichia coli is described. Testing of 959 strains resulted in 78 biotypes. On repeated testing, 96% of 182 strains had identical biotypes or differed by only one test. This system provides satisfactory differentiation among strains and is reproducible. Precise standardization of inoculum size is not required. Multiple inoculation allows time and cost-efficient testing of large numbers of strains.

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During the 19-month period from June 1976 to December 1977, 90 patients became colonized or infected with gentamicin-resistant Staphylococcus aureus (GRS). Of 63 adults, 56 had hospital-acquired GRS, whereas only 9 of 27 children had hospital-acquired GRS (P < 0.001). The other 7 adults and 18 children had GRS present on admission. More than half of those who acquired GRS in the hospital had received prior aminoglycoside therapy. Attack rates were higher in adults than in children and significantly higher on the plastic surgery service than on any other adult service. Phage typing revealed a single-strain outbreak on the plastic surgery ward involving 11 patients, whereas other isolates were of several phage types. Community-acquired GRS occurred more frequently in rural native communities (P < 0.02) and may be related to the use of topical gentamicin. Of 17 native children, 10 were from the same area but there was no common phage type. Agar dilution minimal inhibitory concentration (MIC) testing confirmed that all isolates were gentamicin resistant (MIC >/= 8 mug/ml) and almost all were tobramycin resistant (MIC >/= 8 mug/ml). Although the MIC distribution between gentamicin disk-susceptible and -resistant strains was significantly different, MIC's for 90% of gentamicin disk-resistant strains were

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Netilmicin, a new semisynthetic aminoglycoside antibiotic, was used to treat 41 infections in 38 patients. The outcome of four infections could not be evaluated: two patients received inadequate therapy and two did not have gram-negative infections. Clinical improvement occurred in 36 (97%) of the 37 gram-negative infections, and bacteriologic cure occurred in 30 (86%) of the 35 evaluable infections. Therapeutic serum concentrations of netilmicin were readily achieved by both intramuscular and intravenous routes. Reversible ototoxic effects occurred in 1 (3%) of 35 courses of therapy evaluated, reversible nephrotoxic effects occurred in 5 (14%) of 36 courses and mild reversible alterations in liver function occurred in 3 (19%) of 34 courses. Netilmicin appears to be effective and safe in the treatment of aerobic gram-negative infections.

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The authors review 23 cases of hospital-acquired meningitis occurring over a 15 year period in neurosurgical patients. Factors associated with the development of meningitis include recent craniotomy, cerebrospinal fluid leak, the presence of ventricular or lumbar drainage tubes, and skull fracture. Four cases were caused by Staphylococcus epidermidis; one of these patients died. In 19 cases, Gram-negative enteric bacteria were the etiologic agents, most commonly members of the Klebsiella-Enterobacter-Serratia group. Eleven of these patients died. The particular antibiotic or group of antibiotics used and the route of administration made no difference in the outcome of Gram-negative bacillary meningitis.

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