Enterococci, most often Enterococcus faecalis, cause 5%-20% of cases of infective endocarditis (IE). Enterococcal IE is usually a disease of older men, and the most frequent source of infection is the genitourinary tract. In cases of enterococcal IE, both normal and previously damaged valves can be involved. The disease most commonly presents in a subacute fashion; clinical and laboratory features are similar to those observed with IE caused by other pathogens. Diagnosis is based on the presence of clinical criteria of IE in association with positive blood cultures. Optimal therapy entails the parenteral use of a cell wall-active agent (penicillin G, ampicillin, or vancomycin) in combination with streptomycin or gentamicin in cases caused by enterococcal strains with high-level resistance to streptomycin. A 4-week treatment course may be adequate in many cases. In patients with streptomycin-resistant strains, mitral valve disease, illness of greater than 3 months' duration, and/or relapse after previous therapy, a 6-week treatment course should probably be administered. With standard treatment and the appropriate use of valve replacement, a cure rate of approximately 85% can be expected.

We report two cases of Nocardia cyriacigeorgica septicemia and disseminated infection in the setting of profound immunodeficiency. In both instances, diagnosis was rapidly facilitated by 16S rRNA gene sequencing of blood culture isolates. These constitute the first confirmed reports of Nocardia cyriacigeorgica bloodstream infection in humans.CASE REPORTS Case 1. The patient was a 69-year-old woman with type 2 diabetes mellitus, chronic lymphocytic leukemia, and hypogammaglobulinemia who presented to hospital "A" with a 3-week history of malaise, right-sided flank and pleuritic chest discomfort, left leg weakness, and an ataxic gait. She denied any fever, chills, cough, or weight loss. Baseline laboratory studies revealed neutrophilia, lymphocytosis, anemia, and hyponatremia. Radiologic studies demonstrated patchy and nodular infiltrates in the right lung, bilateral pleural effusions, multiple ring enhancing lesions in the cerebellum and cerebrum, and a right adrenal mass. Upon the patient's admission to hospital, three sets of BacT/Alert FAN (bioMerieux Inc., Durham, N.C.) aerobic and anaerobic blood cultures were collected, while the adrenal mass was biopsied to rule out infectious and noninfectious etiologies. After 2.5 days of incubation, the aerobic bottle of one of the blood culture sets demonstrated the presence of a partially acid fast, branching, rod-shaped bacterium that formed dry white colonies after overnight growth on 5% sheep blood and Sabouraud dextrose agar media. Respiratory samples were not collected for microbiological analysis. A diagnosis of disseminated nocardiosis was subsequently made, after which the patient received empirical therapy with intravenous meropenem (1 g every 8 h) and oral trimethoprim-sulfamethoxazole (TMP-SMX) (160 and 800 mg, respectively, twice daily). Using Microseq 500 kits and an ABI Prism 3100 genetic analyzer (Applied Biosystems, Foster City, CA), partial sequencing (first 500 bp) of the 16S rRNA gene of the blood culture was successful. A BLAST search (http://www.ncbi.nlm.nih.gov/BLAST/) of the GenBank database revealed 100% homology of our patient's sequence with that of five strains of Nocardia cyriacigeorgica (GenBank accession numbers AB094578, AB115955, AY244782, AY262326, and AB094580) and 98.1% and 97.9% homology with two other N. cyriacigeorgica strains (GenBank accession numbers AF430027 and AF282889, respectively). The adrenal biopsy culture was also positive for N. cyriacigeorgica. The isolate was susceptible to TMP-SMX (MICs, Յ2/38 g/ml), imipenem (MIC, 2 g/ml), and amikacin (MIC, Յ16 g/ml) based on Clinical and Laboratory Standards Institute (CLSI; formerly NCCLS) broth microdilution susceptibility testing (13). The patient's clinical condition gradually improved over the course of her stay in the hospital, but she remained on intravenous meropenem and oral TMP-SMX for several weeks thereafter through the regional home intravenous therapy program. Follow-up radiologic investigations 2 months post-hospital discharge demonstrated complete resolution of t...

The stimulus for the migration of polymorphonuclear leukocytes (PMNs) in acute chlamydial infection was studied in vitro by examining the chemotaxigenic effect of L2 and DE Chlamydia trachomatis elementary bodies (EB) upon the plasma of three healthy donors. In each individual experiment, chemotactic response was assessed with PMNs and plasma from the same respective donor, and no specific antibodies against C. trachomatis were detected in the plasma of any donor. Chemotaxis was observed in an agarose plate assay and was quantitated as the chemotactic differential, or CD (directed migration of PMNs minus random movement of PMNs). For each donor, the mean CD was significantly greater (P less than 0.005) when plasma preincubated for 2 h with L2 EB was used as the chemoattractant than when (i) plasma alone, (ii) plasma preheated to 56 degrees C for 30 min before incubation with L2 EB, or (iii) L2 EB in phosphate-buffered saline (PBS) was used as the potential chemoattractant. Similarly, in the one donor in whom DE EB were studied, the mean CD was also significantly greater (P less than 0.005) for plasma preincubated with DE EB as compared with (i) plasma alone or (ii) DE EB in PBS. Complement activation by C. trachomatis EB was assessed by radioimmunoassay for C5a des-arginine in all chemoattractant preparations used in the chemotaxis assay. Mean C5a des-arginine levels were high in plasma samples preincubated with L2 EB (171.00 +/- 10.64, 107.00 +/- 4.76, and 89.70 +/- 1.74 ng per ml) or DE EB (37.40 +/- 15.76 ng per ml) but were undetectable (less than 4.0 ng per ml) in (i) plasma alone, (ii) preheated plasma incubated with L2 EB, and (iii) PBS containing L2 EB. Thus, L2 EB and DE EB of C. trachomatis exert a chemotaxigenic effect upon normal antibody-negative plasma, and this effect is at least in part a result of complement activation and generation of the potent chemotaxin C5a.

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In this randomized study, a single 800-mg oral dose of cefixime cured 96 of 97 men with uncomplicated gonococcal urethritis, compared with 44 cures of 46 men who received standard therapy with amoxicillin (3 g) plus probenecid (1 g). Both regimens were ineffective against coexistent infection with Chiamydia trachomatis and Ureaplasma urealyticum. Cefixime was well tolerated, and all side effects were mild and self-limited.Cefixime is a novel oral cephalosporin with ,-lactamase stability and in vitro activity similar to that of many of the broad-spectrum cephalosporins (5, 6). Previous studies have revealed that Neisseria gonorrhoeae is highly susceptible to cefixime in vitro (2,5,6). MICs for 90% of isolates of penicillin-susceptible strains as well as for those strains demonstrating penicillinase production and chromosomally mediated resistance have been 0.05 ,ug/ml. Furthermore, it has been shown that a single 400-mg oral dose of cefixime in healthy volunteers results in mean levels in serum of 3.85 ,ug/ml at 4.3 h (peak) and 1.13 ,ug/ml at 12 h following administration (4). Thus, we wished to compare the clinical efficacy and tolerability of a single dose of cefixime (in this case, 800 mg) with those of an established regimen, namely amoxicillin and probenecid, in the treatment of uncomplicated gonorrhea in men.Males aged 18 years and older with positive cultures for N. gonorrhoeae from any site or with gram-negative intracellular diplococci from endourethral or rectal swabs were eligible for study. Patients receiving antimicrobial therapy in the preceding 2 weeks were excluded from the study, as were persons with a history of hypersensitivity to penicillins or cephalosporins and those with serious underlying disorders. All participants provided informed, written consent.At the initial visit, all patients were questioned about symptoms, prior medications, and sexual history and underwent examination of the external genitalia. Endourethral swabs for Gram stain and culture for N. gonorrhoeae, Chlamydia trachomatis, and Ureaplasma urealyticum were collected. Pharyngeal swabs for N. gonorrhoeae culture were obtained from all patients, but rectal swabs were performed only on homosexual and bisexual men. Patients were then randomized in a 2:1 ratio to receive either cefixime (800 mg in four 200-mg capsules) as a single oral dose (without probenecid) or amoxicillin (3.0 g) and probenecid (1.0 g) orally. All men were provided with a diary card to record subsequent side effects, symptoms, and sexual contact, if any. * Corresponding author. Patients were requested to return for follow-up 6 to 9 days after treatment, and men whose cultures were initially C. trachomatis positive and those with persistent symptoms or signs of infection following therapy were encouraged to return 3 and 6 weeks posttreatment. At each follow-up, patients were questioned about side effects, symptoms, and sexual activity. Physical examination was repeated, as were swabs for endourethral Gram stain and N. gonorrhoeae, C. trachomatis, and U. ure...