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Solid tumors rarely present with fever. Among those that do, carcinoma of the colon has been infrequently reported as a primary cause of fever. This patient had carcinoma of the right colon with prolonged fever, but no evidence of infection or gastrointestinal symptoms. At surgical resection, a caecal adenocarcinoma was found with metastases to the mesentery and 10 of 40 lymph nodes. The patient's fever resolved after 3 days. The patient remained healthy during 8 years of follow-up. Right-sided colon cancer is not often considered in the complete evaluation of fever of undetermined cause.

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OBJECTIVE: To evaluate the effect of intermittent (16 h/d) enteral feeding (IEF) on gastric pH and gastric microbial growth in mechanically ventilated patients. DESIGN: Prospective, case-controlled study. SETTING: Medical ICU and infectious disease research laboratory in a university hospital. PATIENT POPULATION: Thirteen mechanically ventilated patients receiving continuous enteral feeding (CEF). METHODS: Gastric pH and quantitative gastric cultures were obtained while patients received CEF. Each patient's feeding schedule was changed to IEF. Daily gastric pH and quantitative gastric cultures were obtained for 5 consecutive days. RESULTS: Gastric microbial growth was found in 85% (11/13) of patients receiving CEF. Implementation of IEF did not clear gastric microbial growth, as only one patient subsequently reverted to negative culture. Similar gastric microbial growth continued in 90% (10/11) of patients after institution of IEF. Gastric pH did not decrease with the administration of IEF (gastric pH with IEF, 3.8 +/- 0.6 vs 4.7 +/- 0.5 with CEF (not significant [NS]). The amount of microbial growth was also unchanged with IEF (total growth with IEF, 7.8 x 10(5) +/- 5.2 x 10(5) cfu/mL vs 8.7 x 10(5) +/- 4.6 x 10(5) cfu/mL with CEF) (NS). Thirty-eight percent (5/13) of patients developed new Gram-negative rod growth in gastric cultures while receiving IEF. Gram-negative rod isolates increased from 25% of total isolates (CEF) to 40% (IEF). CONCLUSION: Our preliminary data suggest gastric pH was not lowered and existing microbial growth was not cleared in ventilated patients receiving IEF after previously receiving CEF. Further controlled study in a larger group of patients is necessary to determine whether IEF is of benefit in decreasing gastric colonization and nosocomial pneumonia.

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Fungal endocarditis is considered an absolute indication for valve replacement surgery. We describe the successful medical treatment of recurrent Candida parapsilosis candidemia with sequential treatment with amphotericin B and fluconazole in a patient with probable prosthetic valve endocarditis. Because of the presumed effectiveness of amphotericin B and fluconazole in the treatment of this patient, medical therapy should be considered as potentially useful in the treatment of recurrent C parapsilosis fungemia or endocarditis or both.

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An open-label, controlled, randomized study was performed to assess the efficacy and safety of combination regimens using either aztreonam or an aminoglycoside control regimen as empiric therapy for suspected aerobic gram-negative bacillary pneumonia or purulent bronchitis. Eighty-four patients, 42 in each arm of the study, were randomly assigned to one of two treatment regimens. The combination aztreonam regimen included aztreonam, 2 gm every 8 hours (q8h), plus either clindamycin, 600 to 900 mg q8h, or nafcillin, 1.5 gm to 2 gm every 6 hours (q6h). The control regimen was one of the following depending on the combination therapy that was designated standard at each of the three study institutions: amikacin, 5 mg/kg q8h, plus cefazolin, 1 gm q8h; amikacin, 500 mg every 12 hours plus mezlocillin, 4 gm q6h; or kinetically dosed tobramycin plus ticarcillin, 3 gm to 4 gm q4h. The two groups were well matched in terms of demographics and clinical characteristics. Among the 84 patients, organisms from the Enterobacteriaceae family accounted for the largest proportion of isolates (44%) including Escherichia coli (13%), Klebsiella species (14%), and Serratia species (9%). Other commonly identified organisms were Pseudomonas aeruginosa (19%), Haemophilus influenzae (15%), Streptococcus pneumoniae (12%), and Staphylococcus aureus (8%). Results of this trial included clinical response rates of 83% in both groups (P = 0.951) and a microbiologic cure rate of 75% in the aztreonam group and 63% in the control group (P = 0.291). In the 59 patients with documented aerobic gram-negative pneumonia, microbiologic eradication rates were 72% in the aztreonam group versus 57% in the control group (P = 0.359). Duration of treatment tended to be shorter in the aztreonam group than in the control group, with a median 10 days of therapy versus 12 days of therapy (P = 0.095), respectively. In addition, the percentage of patients requiring nonstudy antimicrobial agents tended to be lower in the aztreonam group than the control group, involving 21% of patients in the aztreonam group compared with 36% of patients in the control group (P = 0.086). All regimens were well tolerated, and no patient was withdrawn because of adverse reactions to the study medications. Two patients, both in the control group, required dose reduction, which was necessitated by possible aminoglycoside-induced nephrotoxicity. This trial shows that aztreonam is an effective agent with an excellent safety profile when used in combination regimens for the empiric treatment of pneumonia. A well-controlled trial is needed to verify the trend toward shorter hospital stays and a reduced need for additional antimicrobial agents seen with the aztreonam regimen when compared with those receiving aminoglycoside-combination regimens.

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Serratia marcescens bacteremia has become ubiquitous recently. S. marcescens bacteremia, either hospital- or community-acquired, can no longer be treated as insignificant. We reviewed 23 episodes of S. marcescens bacteremia in 1985. Among them, 17 patients (74%) were hospital-acquired infections, while 6 (26%) were community-acquired. Nine patients died, and the case fatality rate was 39%. Eleven patients (48%) had no clinically apparent source of infection, 5 (22%) had urinary tract infection, 3 (13%) had pneumonia, 2 (9%) had biliary tract infection, 1 (4%) had intra-abdominal infection, and 1 (4%) had skin and soft-tissue infection. Nosocomial isolates are often resistant to many antibiotics. Amikacin and the beta-lactamase-stable (third generation) cephalosporins are superior to gentamicin in the treatment of nosocomial S. marcescens bacteremia. We here emphasize that the awareness and treatment of S. marcescens bacteremia in daily clinical practice is unequivocally critical.

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In 1985, 100 episodes of klebsiella pneumoniae bacteremia in 98 patients were treated at the Veterans General Hospital--Taipei. The disease was community acquired in 58% and nosocomially acquired in 42%; unimicrobial in 86% and part of a polymicrobial bacteremia in 14%. Medical records of 90 episodes were available and were analyzed. Portals of entry, in decreasing order of frequency, were hepatobiliary (24%), respiratory (20%), and urinary tract (19%). Diabetes mellitus, which was found in 25 (28%) patients, was the most common underlying disease, followed by malignancies in 13 (14%), biliary tract abnormalities in 9 (10%), and cirrhosis of the liver in 8 (9%). The most frequent clinical findings were fever (89%) and leukocytosis (60%), followed by thrombocytopenia (27%), jaundice secondary to bacteremia (22%) and shock (21%). The course of one (1%) patient, who was diabetic and had a liver abscess, was complicated by metastatic septic endophthalmitis and meningitis. Overall case fatality was 46%. Poor prognostic factors included inappropriate antibiotic therapy, respiratory tract as a portal of entry and the presence of shock. Cephalosporins and aminoglycosides were the most active antibiotics. The use of one or more antibiotics, which included at least one cephalosporin, with in vitro activity against the corresponding isolate, with adequate dosage and an appropriate route of administration significantly reduced deaths directly attributed to K. pneumoniae septicemia, 32% (18/57), compared with 88% (21/24) in patients who were not treated appropriately (p less than 0.001). Combination therapy with a cephalosporin and aminoglycoside in conjunction with surgery in selected cases is the treatment of choice for K. pneumoniae bacteremia.

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The efficacy of short-course ceftriaxone monotherapy in treatment of bacteremia was evaluated in an open protocol. Patients with laboratory-proven bacteremia were randomly treated with one of three dosing schedules for a duration of 5 to 7 days. Fifty-seven (62%) out of the 92 evaluable infections had successful results. Successful responses were seen in 20 (59%) out of 34 infections given 4 g every 24 hours, 15 (54%) out of 28 given 2 g every 12 hours, and 22 out (73%) of 30 given 2 g every 24 hours. The results showed no significant differences. The cases evaluated as failures were largely due to infections with resistant organisms or inadequate drainage of the primary infectious foci. Forty-nine (94%) of the 52 infections had successful results with one of the short-course treatment regimens, provided that they had no factors indicative of a poor prognosis. We stress the importance of anti-microbial susceptibility and adequate removal of the primary foci in the treatment of bacteremia. Our experience indicates that once-daily administrations of 2 g ceftriaxone as monotherapy is preferred for short-course treatment of bacteremia since it is equally effective, but more economical than higher dose regimens.

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68 patients presented to the Veterans General Hospital, Taipei with nonenterococcal group D streptococcal septicemia in the years 1985-1987. 36 patients (53%) had nonenterococci as part of a polymicrobial bacteremia. The large intestine was not examined in most patients. Five patients (7%) had associated colonic carcinoma, and 17 patients (25%) had colorectal diseases. Only 7/68 patients (10%) were clinically diagnosed as having infective endocarditis by the doctors in charge. The others were regarded as having septicemia. The charts of these patients were reviewed retrospectively to diagnose infective endocarditis based on strict definitions. One (1%) had definite endocarditis proved at autopsy. 16 patients (24%) had probable endocarditis due to the presence of either a new regurgitant murmur or both a predisposing heart disease and embolic phenomena; 39 (57%) had possible endocarditis based on evidence of having either a predisposing heart disease or embolic phenomena; and only 12 (18%) had no evidence of endocarditis. 27 patients (40%) had at least one predisposing heart disease associated with endocarditis. 51 patients (75%) had at least one lesion suggesting embolic phenomena. 30 patients (44%) had electrocardiographic abnormalities. This high incidence of arrhythmia in nonenterococcal septicemia is of particular interest and could be related to cardiac involvement in some patients. The overall mortality, 62% (42/68), was extremely high in our series, but in those who were clinically diagnosed and treated as infective endocarditis, the mortality was low, 14% (1/7). We suggest all patients with nonenterococcal septicemia associated with either heart disease or lesions of CNS, lung, heart, kidney or limbs suggesting embolic phenomena should be regarded as having possible or probable endocarditis. Treating such patients as having infective endocarditis may reduce the mortality in nonenterococcal septicemia.

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Arthritis caused by Sporothrix schenckii may not respond satisfactorily to a full course of intravenous amphotericin B therapy. Left untreated, the fungus continues to be recovered from cultures of joint fluid, and the patient typically has serious joint disability. We have shown in one patient with sporotrichosis of the knee that direct low-dose injections of amphotericin B can be performed safely, resulting in eradication of the fungus. The patient has had continued useful range of motion and weight bearing on the involved knee.

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Amphotericin B methyl ester (AME) has been used to treat fungal infections, most often those caused by Coccidioides immitis. We describe the only patient with disseminated histoplasmosis who has been treated with AME. After having had alarming reactions to amphotericin B, the patient was treated and cured with AME without adverse drug effect or later relapse.

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Eosinophilia as a manifestation of coccidioidomycosis may be found in blood or cerebrospinal fluid. We report on a case of coccidioidomycosis with pleurisy, skin lesions, and meningitis with concomitant striking eosinophilia in both blood and cerebrospinal fluid that resolved promptly after amphotericin B therapy was started.

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Nutritional therapy of patients receiving mechanical ventilation includes enteral feeding. To determine the frequency of gastric microbial colonization in patients receiving enteral nutrition, 18 patients with acute respiratory failure receiving ventilation were studied. Multiple sources of tracheal colonization were then evaluated to determine the frequency of tracheal transmission of gastric flora and the relationship of gastric colonization and transmission to nosocomial respiratory infection. The stomach was colonized in every patient who received enteral feeding. Tracheal colonization occurred in 89 percent (16 of 18) of patients. In 12 of these 16 patients, 14 organisms colonized the trachea after transmission from the stomach and/or oropharynx. Thirty-six percent (five of 14) of organisms transmitted to the trachea originated from the stomach, whereas another 36 percent (five of 14) were first recovered from the oropharynx. Four tracheally transmitted organisms were first recovered simultaneously from the stomach and oropharynx. Nosocomial respiratory infection developed in 11 patients (63 percent). Three infections occurred during the six-day study period, one of which was associated with transmission of a gastric organism. Multiple sources of tracheal colonization occur in patients receiving enteral nutrition. The stomach is an important source of tracheal colonization. Enteral nutrition can be associated with gastric flora colonizing the trachea and causing nosocomial respiratory infection.

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The efficacy and safety of imipenem/cilastatin was evaluated in a multicenter study. For 49 of the 78 patients with 79 infections entered into the study, the clinical and bacteriologic efficacy of therapy could be evaluated. Toxicity data were analyzed for all 79 infections. Overall, 35 of 49 infections were cured or improved: 10 of 11 cases of pneumonia; 8 of 15 cases of pyelonephritis; 4 of 5 cases of osteomyelitis; 3 of 4 intravascular infections; 6 of 9 soft tissue infections; and 4 of 5 miscellaneous infections. There were 13 bacteriologic failures; superinfections with resistant organisms (i.e., Candida albicans, methicillin-resistant Staphylococcus epidermidis, and Pseudomonas maltophilia) occurred in three patients; reinfection with sensitive pathogens complicated one urinary tract infection; relapses developed of five urinary tract infections and of one case of endarteritis; and bacteriologic persistence occurred in three soft tissue infections. Infections with Pseudomonas aeruginosa were the most difficult to treat. In only six of 11 P. aeruginosa infections was both bacteriologic and clinical cure achieved. Adverse effects were minimal; no serious hematologic or hepatic toxicity and no adverse renal effects were noted.

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