To our knowledge, this is the first clinical description of bloodstream infection caused by tigecycline-non-susceptible A. baumannii. Such resistance appears to be at least partly attributable to an efflux pump mechanism. Given the reported low serum tigecycline levels, we urge caution when using this drug for treatment of A. baumannii bloodstream infection.

For commonly encountered gram-negative bacilli, a MIC of cefepime of 8 g/ml or less was defined by the Clinical and Laboratory Standards Institute as "susceptible" prior to the commercial release of the antibiotic. We assessed 204 episodes of bacteremia caused by gram-negative organisms for which patients received cefepime (typically 1 to 2 g every 12 h) as the primary mode of therapy. The cefepime MIC breakpoint derived by classification and regression tree (CART) software analysis to delineate the risk of 28-day mortality was 8 g/ml. Patients infected with gram-negative organisms treated with cefepime at a MIC of >8 g/ml had a mortality rate of 54.8% (17/31 died), compared to 24.1% (35/145 died) for those treated with a cefepime MIC of <8 g/ml. The rate of mortality for those treated with a cefepime MIC of 8 g/ml was 56.3% (9/16 died), compared to 53.3% (8/15 died) for those treated with cefepime at a MIC of >8 g/ml. A multivariable analysis including severity of illness indices showed that treating patients with bacteremia due to gram-negative organisms with a cefepime MIC of >8 g/ml was an independent predictor of mortality (P < 0.001). There was no significant difference in outcome according to the dosage regimen utilized. Pharmacodynamic assessments that were presented previously would suggest that cefepime treatment (particularly a dosage of 1 g every 12 h) has a low probability of target attainment associated with successful in vivo outcome when the cefepime MIC is >8 g/ml. It would appear reasonable, based on pharmacodynamic and clinical grounds, to lower the breakpoints for cefepime in countries where the cefepime dosage of 1 to 2 g every 12 h is the licensed therapy for serious infections, so that organisms with a cefepime MIC of 8 g/ml are no longer regarded as susceptible to the antibiotic.Breakpoints for differentiating between organisms that are susceptible or resistant to antimicrobial agents are determined by several different organizations. These organizations, including the U.S. Food and Drug Administration (FDA), the Clinical and Laboratory Standards Institute (CLSI), the European Committee on Antimicrobial Susceptibility Testing (EUCAST), and various national organizations, determine breakpoints for antimicrobial susceptibility at the time an antibiotic is undergoing approval for clinical use. Such breakpoints may also be revised when microbiologic, pharmacodynamic, or clinical information suggests a medical necessity to do so. Cefepime breakpoints for gram-negative bacilli were determined prior to the drug's commercial release more than a decade ago. The current breakpoints determined by the FDA and CLSI for the cefepime MIC against infection by the Enterobacteriaceae family, Pseudomonas aeruginosa, and Acinetobacter spp. are Յ8 g/ml (susceptible), 16 g/ml (intermediate), and Ն32 g/ml (resistant). In contrast, EUCAST breakpoints for cefepime MIC against the Enterobacteriaceae family are Յ1 g/ml (susceptible), 2 to 8 g/ml (intermediate), and Ͼ8 g/ml (resistant); and EUCAST breakpoints for ce...

A patient with chronic granulomatous disease developed brain abscesses with Scedosporium prolificans. In vitro susceptibility revealed a synergistic effect of terbinafine and voriconazole. He received therapy with both these antifungals which resulted in disappearance of the brain abscesses. This is the first reported cure of a CNS S. prolificans infection in an immunocompromised host.

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BackgroundNo published study has analyzed emergency department (ED) utilization by human immunodeficiency virus (HIV)-positive adults in the highly active antiretroviral therapy (HAART) era.AimsThe purpose of this study is to describe the demographic and HIV-specific variables associated with ED utilization by HIV-positive adults and their diagnoses when discharged from the ED or subsequently from the hospital.MethodsWe conducted a retrospective cohort study of all HIV-positive adults cared for at a tertiary center HIV clinic and ED (1 January–31 December 2006). Demographic, HIV clinical, and HIV lab variables were abstracted from the clinic database. ED/hospital diagnoses coded by the ICD-9 Diseases/Injuries Tabular Index were abstracted from identified discharge records. We used multivariate logistic regression to compute odds ratios (OR) of ED utilization based on the abstracted variables. We described the cohort and diagnoses using descriptive statistics.ResultsA total of 356 patients met inclusion criteria. Their mean age was 42.7 years, and 77.2% of included patients were male; 52.5% were Caucasian and 47.5% non-Caucasian; 72 patients (20.2%) presented to the ED during the study period [153 visits; 37 (10.4%) required hospitalization (61/153 visits)]. Income level and mean 2006 viral load had a significant association (p < 0.05) with ED utilization. Of 155 ICD-9 ED discharge diagnoses, ill-defined symptoms/signs (25.2%), injury (18.7%), and musculoskeletal disorders (11.6%) were most prevalent. Of 450 ICD-9 hospital discharge diagnoses, endocrine/metabolic (13.3%), psychiatric (12.2%), infectious/parasitic (12%), and circulatory disorders (11.8%) were most prevalent.ConclusionIn this study of HIV-positive adults, income level and mean 2006 viral load had a significant association with ED utilization. Noninfectious diagnoses were alone most prevalent in ED discharged, but not hospitalized, patients.