Kluyvera is a relatively newly described genus in the family Enterobacteriaceae that infrequently causes infections in humans. The organism has been isolated from various clinical specimens, but its significance has not been clearly established. In fact, it has been regarded alternatively as saprophytic, opportunistic, or pathogenic. Since the redefinition of this genus in 1981, case reports of diverse clinical infections occurring under various host conditions have been published. Here we present a critical review of all Kluyvera infections reported in the literature, along with our experience involving 5 additional cases. Most patients received prompt antimicrobial treatment on the basis of susceptibility testing, and overall the clinical outcomes were good. Antimicrobial agents active against most Kluyvera strains include third-generation cephalosporins, fluoroquinolones, and aminoglycosides. In contrast, the resistance to ampicillin, extended-spectrum penicillins, and first- and second-generation cephalosporins is significant. Kluyvera is a potentially virulent pathogen that deserves aggressive treatment designed with an awareness of the organism's antimicrobial resistance patterns.

Patients with blood cultures positive for gram-positive cocci were enrolled in a prospective randomized double-blind comparative trial of vancomycin at 15 mg/kg every 12 h versus teicoplanin at 6 mg/kg every 12 h for three doses and then 6 mg/kg every 24 h. A total of 54 patients were randomized, and 40 were evaluable. Of the 40, 9 had infection of indwelling vascular catheters. Four infections were due to Staphylococcus aureus, and five were due to Staphylococcus epidermidis. In concert with catheter removal, all patients were treated successfully, regardless of which drug they were taking. Of 31 patients without an indwelling catheter, 19 were infected with S. aureus, and 12 of the 19 had either endocarditis or mycotic aneurysm. Six of eight patients given teicoplanin failed treatment, as opposed to one of four patients given vancomycin (P = 0.14). Of greater concern, four of four patients with left-sided endocarditis or mycotic aneurysm failed to recover when given teicoplanin, as opposed to one of three patients given vancomycin (P = 0.07). Although not quite statistically significant, the unexpectedly high number of treatment failures with teicoplanin resulted in a decision to discontinue patient enrollment. It is suggested that future trials explore the efficacy of larger doses of teicoplanin.Teicoplanin is a new glycopeptide antibiotic chemically related to the vancomycin-ristocetin group of antibiotics (10, 25). The teicoplanin MIC for 90% of strains of methicillinsusceptible Staphylococcus aureus is 0.4 pug/ml (19), and the serum half-life ranges from 40 to 100 h (10, 25). The long serum half-life and the low MIC for 90% of strains suggest that teicoplanin would be effective in a once-daily dosage regimen against serious infections due to methicillin-susceptible S. aureus.The average peak concentration in serum after a 3-mg/kg (of body weight) dose of teicoplanin is 7 ,ug/ml, with a trough concentration some 23 h later of 2 ,ug/ml (23). On the basis of these levels and the in vitro MICs for 90% of strains, the initial clinical trials were conducted with a teicoplanin loading dose of 6 mg/kg and then a once-daily dose of 3 mg/kg. This regimen proved inadequate for severe S. aureus infections (3, 12

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