Daptomycin is a new lipopeptide antibiotic that is rapidly bactericidal against Staphylococcus aureus. We report daptomycin resistance and treatment failure in 2 patients with osteomyelitis due to methicillin-resistant S. aureus. Disk diffusion susceptibility testing failed to detect resistance. Daptomycin at high concentration retained bactericidal activity against resistant isolates.

Metabolic abnormalities and cardiovascular disease are increasingly recognized in HIV-infected patients. While HIV-infected patients older than 50 years of age account for up to 25% of HIV cases in the United States, there are limited data on these individuals. To determine the prevalence and predictors of the metabolic syndrome among a cohort of older, HIV-infected patients and to calculate their 10-year Framingham cardiac risk (FCR) score a cross-sectional study of HIV patients older than 50 years of age was conducted at the CORE Center, Chicago, Illinois, between May 2005 and February 2006. There were 121 HIV-infected patients with a median age of 54 years, of whom 79% were male, 83% African American, 9% Hispanic, and 6% Caucasian. Thirty-four percent of patients had the metabolic syndrome, 49% had a moderate-high (>10%) 10-year FCR, and 13% had a high (>20%) 10-year FCR. Patients with the metabolic syndrome were significantly more likely to have a greater than 20% 10-year FCR. Sixty-five percent of all patients were current smokers and 55% of patients with the metabolic syndrome were current smokers. There were significant differences in the components of the metabolic syndrome by gender with women having significantly more components related to insulin resistance such as elevated waist circumference and diabetes, while men were more likely to have low high-density lipoprotein (HDL) levels. This study shows a high prevalence of the metabolic syndrome in older HIV-infected patients and an association between the metabolic syndrome and FCR in our study population. As the HIV population ages, attention to modifiable cardiac risk factors will become increasingly important.

We report four adult patients who presented with septic pulmonary emboli and community-acquired methicillin-resistant Staphylococcus aureus bacteremia associated with deep tissue infections, such as pyomyositis, osteomyelitis, and prostatic abscess. The patients lacked evidence of right-sided endocarditis or thrombophlebitis. This association, previously described in children, may also be important in adults. CASE REPORTFour adult patients from the community presented to a large urban hospital (John H. Stroger Jr. Hospital of Cook County, Chicago, IL) with septic pulmonary emboli and community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) bacteremia from December 2005 to February 2007. Each patient underwent a transesophageal echocardiogram that was negative for endocarditis. In addition, clinical and radiographic evaluations for deep-vein thrombosis were negative. No history or stigmata of intravenous drug use, thrombophlebitis, or prior intravascularcatheter use were found. Instead, each patient was diagnosed with a deep tissue infection or abscess as a possible primary focus of infection.Patient 1. A 36-year-old obese man with type 2 diabetes mellitus presented with 1 week of fever, cough, chest pain, and difficulty walking. Computed tomography (CT) of the chest demonstrated bilateral pulmonary nodules, some cavitary, consistent with septic pulmonary emboli (Fig. 1a). Blood cultures grew MRSA on admission and remained positive for 12 days. Despite receipt of appropriate antimicrobials, the patient remained intermittently febrile for 3 weeks. CT of the abdomen/ pelvis, as well as magnetic resonance imaging (MRI) of the spine did not reveal thrombophlebitis or abscess. On hospital day 25, a gallium scan demonstrated increased uptake in the left thigh. CT of the lower extremities revealed an enhancing fluid collection extending the full length of the left quadriceps muscle, consistent with pyomyositis, without evidence of deepvein thrombosis (Fig. 1c). Surgical drainage revealed grampositive cocci in clusters on Gram stain; the culture (obtained during vancomycin therapy) was negative. The patient defervesced after drainage and recovered with 6 weeks of vancomycin therapy. Patient 2.A 55-year-old man with a history of hypertension, benign prostatic hypertrophy, and chronic rectal hemorrhoids was admitted with urinary hesitancy and rectal pain for 4 days. He had chills, but no pulmonary complaints. On examination, the patient was febrile and had large nonbleeding external rectal hemorrhoids and an enlarged nontender prostate. Blood cultures from the first 6 days of hospitalization were positive for MRSA. Pelvic CT revealed an enhancing cystic lesion in the inferior aspect of the prostate, consistent with a prostatic abscess, without evidence of pelvic thrombophlebitis (Fig. 1d). Pulmonary nodules consistent with septic pulmonary emboli were noted on CT. The patient was treated with 4 weeks of vancomycin and improved without surgical drainage.Patient 3. A 45-year-old man was admitted with acute lo...