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Biomedical subjects

M B Goetz

Publications and source records attributed to M B Goetz.

At least 37 records · Page 2Linked to original sources
PubMed1997

A meta-analysis of the relative efficacy and toxicity of single daily dosing versus multiple daily dosing of aminoglycosides.

We performed a meta-analysis of the efficacy and toxicity of single daily dosing (SDD) vs. multiple daily dosing of aminoglycosides and summarized the results of the four previously published meta-analyses on this subject. Our analysis showed that the overall clinical response rate favored SDD therapy (mean difference, +3.06%; 95% confidence limit [CL], +0.17% to +5.95%; P = .04). However, we found no significant difference in the overall microbiological response rates (mean difference, +1.25%; 95% CL, -0.40% to +2.89%) or in the clinical response rates (mean difference, +0.62%; 95% CL, -2.48% to +3.71%) when patients who received adjunctive antimicrobial therapy were excluded from the analysis. No significant differences were found in the incidences of nephrotoxicity, ototoxicity, or vestibular toxicity; the summary differences in the rates of these toxicities were -0.18% (95% CL, -2.17% to +1.81%), +1.38% (95% CL, -0.99% to +3.75%), and -3.05% (95% CL, -10.69% to +4.59%), respectively. These results are similar to those of the previously published meta-analyses.

Adult↗
PubMed1994

Nosocomial transmission of disease caused by nontypeable strains of Haemophilus influenzae.

PURPOSE: The authors evaluated a geographic and temporal cluster of lower respiratory tract infections due to unencapsulated (serologically nontypeable) Haemophilus influenzae to determine whether this event represented the transmission of a single clone. METHODS AND MATERIALS: H influenzae was recovered from eight patients at a nursing home and from three patients in an adjacent acute care hospital. Serotypes, biotypes, outer membrane protein profiles, and multilocus enzyme genotypes were determined to characterize bacterial isolates. Patient records were retrospectively examined to determine clinical and epidemiologic characteristics. RESULTS: During a 10-day period in September 1991, lower respiratory tract infections caused by H influenzae were diagnosed in four patients residing in a single nursing home unit. Oropharyngeal cultures from four of seven asymptomatic roommates of these patients also grew H influenzae. During the month before and after the nursing home cluster of cases, four other individuals in acute care areas of the hospital had positive sputum cultures for H influenzae. Three of these latter specimens were also available for analysis. All H influenzae isolates were unencapsulated and beta-lactamase-negative. Eight of the nine isolates from the nursing home patients (two morphologically distinct colony types of H influenzae were isolated from one case) had a single outer membrane protein profile arbitrarily designated as X and a single multilocus enzyme genotype arbitrarily designated as A. In contrast, none of the isolates from the acute care cases had this profile (P < or = 0.02; two-tailed Fisher's exact test). The isolates obtained from two of the patients in acute care areas had an outer membrane protein profile arbitrarily designated as Y and a single multilocus enzyme genotype designated as B. These two patients were contemporaneously hospitalized in adjacent intensive care unit cubicles. The remaining isolates displayed an outer membrane protein profile arbitrarily designated as W. All roommates of the four patients in the nursing home were administered oral rifampin 600 mg daily for 4 days. H influenzae was not recovered from follow-up oropharyngeal cultures obtained 1 week after the completion of therapy. No beta-lactamase-negative H influenzae were identified in this unit during the subsequent 9 months. CONCLUSION: This study furnishes strong evidence for the nosocomial transmission of a clone of unencapsulated H influenzae in a nursing home unit. Epidemiologic data showed temporal and geographic clustering of respiratory tract infections and colonization by H influenzae. Outer membrane protein profiles and multilocus enzyme genotype analysis indicated that seven of eight patients at the nursing home carried a single clone of unencapsulated H influenzae. Laboratory and epidemiologic data also demonstrated the presence, and possible nosocomial transmission, of a second clone of unencapsulated H influenzae in a physically separate area of the hospital. Finally, although a causal relationship is not proven, the outbreak ended following the administration of rifampin prophylaxis of asymptomatic carriers.

Bacterial Outer Membrane Proteins↗
PubMed1994

Azole-resistant Candida albicans: report of two cases of resistance to fluconazole and review.

We report the course of oropharyngeal infection by Candida albicans that was refractory to treatment with fluconazole in two patients infected by the human immunodeficiency virus (HIV). We also review the epidemiology of C. albicans with decreased in vitro and in vivo susceptibility to azole antifungal agents, the significance of such isolates, the known mechanisms by which C. albicans may become less susceptible to azole antifungal agents, and the efficacy of various treatments for mucosal candidiasis. The occurrence in HIV-infected patients of mucosal candidiasis that is refractory to therapy with fluconazole and is due to C. albicans that demonstrates decreased in vitro susceptibility to fluconazole has been reported since 1990. Following the release of miconazole and ketoconazole in the late 1970s, C. albicans with decreased in vitro susceptibility to these agents was isolated from patients with chronic mucocutaneous candidiasis who required repeated and prolonged courses of therapy. Subsequently, C. albicans with decreased in vitro-susceptibility to ketoconazole, clotrimazole, and itraconazole has been isolated from HIV-infected patients. Recent reports of the sexual and nosocomial transmission of wild-type C. albicans indicate the possibility of future person-to-person transmission of C. albicans with decreased in vitro susceptibility to azole antifungal agents.

AIDS-Related Opportunistic Infections↗
PubMed1993

Clinical and laboratory features of measles in hospitalized adults.

PURPOSE: Description of the epidemiology, morbidity, and mortality of hospitalized adults with typical measles. PATIENTS AND METHODS: Retrospective case analysis of 33 adults who required acute care for complications of measles in a public hospital in Los Angeles, California. The diagnosis of measles was established on standard clinical or serologic grounds. RESULTS: Of 68 patients (age greater than 14) with signs and symptoms of measles who presented for medical care, 33 (19 males and 14 females) required hospitalization; 18 were natives of the United States. The patient age was 26.1 +/- 7.3 (mean +/- SD) years; four patients, all natives of the U.S., were born before 1957. The duration of hospitalization was 6.8 +/- 8.8 days for all patients and 13.4 +/- 14.2 days for the nine patients who required intensive care unit (ICU) care. Six of the ICU patients required mechanical ventilation for 11.0 +/- 15.0 days; two deaths occurred among these patients. During the course of their illness, 7 of 25 (28%), 11 of 28 (39%), 6 of 28 (21%), and 5 of 16 patients (31%) had peak lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, and creatine kinase values, respectively, that were greater than 5 times the upper limit of normal. Fifteen of 28 patients (54%) developed total serum calcium levels less than or equal to 2.0 mmol/L. Ten cases were serologically confirmed; 23 cases were diagnosed as probable measles on clinical grounds. There were no significant demographic, clinical, or laboratory differences between patients with confirmed and probable measles. No patients had characteristic manifestations of atypical measles. The sole immunocompromised patient died. CONCLUSIONS: Measles in adults may result in severe, life-threatening complications that utilize substantial medical resources. Physicians need to appreciate the clinical presentations and manifestations of severe measles in adults and to provide measles vaccine to nonimmune adults during community-wide outbreaks.

Adolescent↗
PubMed1993

Nephrotoxicity of vancomycin and aminoglycoside therapy separately and in combination.

There is conflict by evidence as to whether therapy with vancomycin plus an aminoglycoside is more nephrotoxic than therapy with either agent alone. Here we report the results of a prospective, non-randomized, open-label study of the incidence of nephrotoxicity in elderly patients who received vancomycin alone (32 patients) or an aminoglycoside alone (67 patients) or in combination (37 patients). The mean (95% confidence limits) incidence of nephrotoxicity, defined as an increase of > or = 44.2 mumol/L in the serum creatinine, was 19% (5-32%) in patients receiving vancomycin alone, 24% (10-38%) in patients receiving vancomycin plus an aminoglycoside, and 12% (4-20%) in patients receiving an aminoglycoside alone (P > 0.05 for all comparisons). The corresponding absolute increases of the serum creatine were 20.3 +/- 23.0 mumol/L (-24.8 to +65.4 mumol/L), 37.1 +/- 53.0 mumol/L (-67.2 to +140.4 mumol/L), and 22.1 +/- 31.8 mumol/L (-40.7 to +94.6 mumol/L). The absolute increase was significantly greater (P < 0.05) in patients receiving vancomycin plus an aminoglycoside than in patients receiving an aminoglycoside alone. A meta-analysis of seven previously published studies combined with our data revealed that the incidence of nephrotoxicity associated with combination therapy is 13.3 +/- 3.1% (7.3-19.4%) greater than therapy with vancomycin alone (P < 0.01) and 4.3 +/- 1.4% (1.6-7.0%) greater than therapy with an aminoglycoside alone (P < 0.05). The clinical relevance of this finding may be limited in that the mean duration of antimicrobial therapy in three of the studies was greater than 21 days.

Aged↗
PubMed1993

Randomized double-blinded trial of rifampin with either novobiocin or trimethoprim-sulfamethoxazole against methicillin-resistant Staphylococcus aureus colonization: prevention of antimicrobial resistance and effect of host factors on outcome.

Methicillin-resistant Staphylococcus aureus (MRSA) is a major pathogen in hospitals. Current antimicrobial regimens for eradicating colonizing strains are not well defined and are often complicated by the emergence of resistance. The combination of novobiocin plus rifampin in vitro and in vivo was found to prevent the emergence of resistant populations of initially susceptible strains of MRSA, particularly resistance to rifampin. We therefore studied, in a randomized, double-blind, multicenter comparative trial, the combination of novobiocin plus rifampin versus trimethoprim-sulfamethoxazole (T/S) plus rifampin in order to determine the efficacy of each regimen in eradicating MRSA colonization and to further characterize the host factors involved in the response to this antimicrobial therapy. Among the 126 individuals enrolled in the study, 94 (80 patients; 14 hospital personnel) were evaluable. Among the 94 evaluable subjects, no significant demographic or medical differences existed between the two treatment groups. Successful clearance of the colonizing MRSA strains was achieved in 30 of 45 (67%) subjects receiving novobiocin plus rifampin, whereas successful clearance was achieved in 26 of 49 (53%) subjects treated with T/S plus rifampin (P = 0.18). The emergence of resistance to rifampin developed more frequently in 14% (7 of 49) of subjects treated with T/S plus rifampin than in 2% (1 of 45) of subjects treated with novobiocin plus rifampin (P = 0.04). Restriction endonuclease studies of large plasmid DNA demonstrated that the same strain was present at pretherapy and posttherapy in most refractory cases (24 of 29 [83%] subjects). Among the 56 successfully treated subjects, clearance of MRSA was age dependent: 29 of 36 (80%) subjects in the 18- to 49-year-old age group, 19 of 35 (54%) subjects in the 50- to 69-year-old age group, and 8 of 23 (35%) in the 70- to 94-year-old age group (P < 0.01). Clearance was also site dependent; culture-positive samples from wounds were related to a successful outcome in only 22 (48%) of 46 subjects, whereas culture-positive samples from sites other than wounds (e.g., nares, rectum, and sputum) were associated with a success rate of 34 of 48 (71%) subjects (P = 0.02). Foreign bodies in wounds did not prevent the eradication of MRSA by either regimen. T/S plus rifampin was less effective in clearing both pressure and other wounds, whereas novobiocin plus rifampin was equally effective in clearing both pressure and other wounds. There were no significant differences in toxicity between the two regimens. Thus, the combination of novobiocin plus rifampin, in comparison with T/S plus rifampin, was more effective in preventing the emergence of resistance to rifampin and demonstrated a trend toward greater activity in clearing the MRSA carrier state. The response to either combination depended on host factors, particularly age and the site of MRSA colonization.

Adolescent↗
PubMed1993

Toxoplasma gondii peritonitis.

Toxoplasma gondii most often causes encephalitis in HIV-infected patients; infections of other organs are much less often clinically apparent. In particular, peritonitis caused by T. gondii in an Human Immunodeficiency Virus (HIV)-infected patient has been reported only once previously. Herein we report a second case.

Adult↗
PubMed1992

Severe hepatotoxicity in a patient receiving both acetaminophen and zidovudine.

We report the development of severe hepatotoxicity in a patient on zidovudine therapy who received 3.3 g of acetaminophen in less than 36 hours. Three days later, the patient's serum aspartate aminotransferase level was 5,724 U/L, alanine aminotransferase was 3,124 U/L, lactate dehydrogenase was 12,675 U/L, alkaline phosphatase was 84 U/L, and total bilirubin was 20 mumol/L. These values substantially improved over the ensuing 4 days. Serologic results for hepatitis B, hepatitis A, and cytomegalovirus were all negative. The pattern and time sequence of transaminase elevation in this patient are consistent with acute acetaminophen hepatotoxicity, especially since zidovudine-induced hepatotoxicity is described as producing cholestasis rather than acute hepatitis. We hypothesize that our patient's susceptibility to acetaminophen-dependent hepatotoxicity may have been augmented by competitive utilization of glucuronidation by other drugs such as zidovudine and/or trimethoprim-sulfamethoxazole with subsequent increased cytochrome P450-dependent metabolism of acetaminophen. Additionally, due to malnutrition and/or to human immunodeficiency virus infection per se, our patient may have had decreased hepatic reserves of glutathione with which to conjugate the toxic acetaminophen product of the P450 system. Although severe acetaminophen-associated hepatotoxicity has not previously been reported in patients receiving zidovudine, we suggest that clinicians be aware of this potential interaction and counsel malnourished patients, especially those with concomitant hepatic disease, to exercise caution when taking both these medications.

Acetaminophen↗
PubMed1992

Management and epidemiologic analyses of an outbreak due to methicillin-resistant Staphylococcus aureus.

PURPOSE: Following implementation of special measures to control a nosocomial outbreak of methicillin-resistant Staphylococcus aureus (MRSA), we used immunoblot typing in conjunction with antimicrobial susceptibility testing to investigate the epidemiology of this event and to determine whether this outbreak represented the failure of infection control measures to limit the spread of previously endemic MRSA strains or the introduction of a new strain of MRSA. MATERIALS AND METHODS: Isolates of MRSA recovered from hospitalized patients were initially categorized on the basis of antimicrobial susceptibility results. Organisms susceptible to ciprofloxacin and/or trimethoprim/sulfamethoxazole were recovered from patients at a relatively constant rate prior to December 1988 and were categorized as endemic isolates. Subsequently, there was an outbreak due to organisms resistant to both of these antibiotics; these were therefore categorized as outbreak isolates. Isolates were later characterized by immunoblot typing. Prior to this analysis, isolates were given code numbers so that clinical and epidemiologic data as well as resistance patterns were not known until this testing was complete. RESULTS: Between January 1986 and November 1988, an average of 3.9 patients per month acquired nosocomial MRSA in the Sepulveda Veterans Administration Medical Center. In contrast, from December 1988 to October 1989, 369 MRSA isolates were collected from 125 patients (an average of 11.4 patients per month). Prior to December 1988, all tested nosocomial isolates of MRSA were susceptible to ciprofloxacin and/or to trimethoprim/sulfamethoxazole. In contrast, the outbreak was due to spread of MRSA isolates resistant to these antibiotics. Immunoblot typing of 204 isolates from 98 individuals identified five distinct immunoblot types of which types B and C were by far the most common. Type B was highly associated with outbreak isolates, whereas type C was associated with endemic isolates (p less than 0.001). All sequential isolates from single patients that belonged to different susceptibility categories demonstrated discordant immunoblot types. In contrast, concordant immunoblot types were observed for 25 of 27 sequential isolates that displayed minor variations in antimicrobial resistance. The institution of more stringent infection control measures was followed by the return of nosocomial MRSA acquisition rates to pre-outbreak levels. Although novobiocin and trimethoprim/sulfamethoxazole were extensively used to treat patients harboring outbreak and endemic isolates, respectively, in no instance was the initial MRSA isolate from any patient resistant to novobiocin and only 6% of initial endemic isolates displayed trimethoprim/sulfamethoxazole resistance. A modest, significant increase in the resistance of endemic isolates to various other antimicrobial agents was noted however. CONCLUSION: Immunoblot analyses provided strong, corroborative evidence that at least two separate strains of MRSA were present during the outbreak and that a newly introduced strain with a distinctive antimicrobial resistance pattern was primarily responsible for the rapid spread of MRSA during the outbreak. The observation that previously effective infection control measures failed to prevent the nosocomial spread of a newly introduced community-acquired MRSA strain suggests that a single set of control measures may not be equally efficacious against all strains of MRSA. In this regard, previously reported variations in resistance to topical antimicrobials and/or antiseptics, and differences in virulence factors such as colonization potential, invasiveness, and survival on fomites, may warrant further study. Control of the outbreak strain of MRSA in our institution did occur after the implementation of more strenuous isolation procedures.(ABSTRACT TRUNCATED)

California↗
PubMed1992

Comparison of mycobacterial lymphadenitis among persons infected with human immunodeficiency virus and seronegative controls.

Lymphadenitis is a common extrapulmonary manifestation of mycobacterial disease in persons with human immunodeficiency virus (HIV) infection. We compared the clinical, mycobacterial, and diagnostic characteristics of mycobacterial adenitis in 11 HIV-seropositive and 29 HIV-seronegative patients. Ninety-three percent of the HIV-seronegative patients and 54% of the HIV-seropositive patients were foreign-born. In contrast to the HIV-seronegative patients, seropositive patients were more likely to be febrile and have negative purified protein derivative skin tests and abnormal chest roentgenograms. Sputum samples were rarely diagnostic in either group. Mycobacterium tuberculosis was the most commonly isolated organism in both groups, although United States-born patients with HIV infection were more likely to be infected with nontuberculous mycobacteria. In contrast to results for seronegative patients, fine-needle aspiration was usually diagnostic in the HIV-seropositive population, especially in those at risk for M. tuberculosis infection. Similarly, the rate at which smears were positive for acid-fast bacilli was significantly higher in the HIV-seropositive group, a circumstance suggesting a higher burden of organisms in this population. Finally, although preceding opportunistic infections were uncommon in the HIV-seropositive group, both tuberculous and nontuberculous adenitis were associated with advanced immunosuppression.

AIDS-Related Opportunistic Infections↗