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Retrospective matched cohort study. Thirty-eight patients with MRSA bacteraemia, treated with co-trimoxazole as the main therapeutic agent, were matched with 76 patients treated with vancomycin as the main agent. The groups were matched for age, sex, functional status, endovascular source of infection, appropriateness of empirical antibiotic therapy, presence of a foreign body, sepsis severity and Charlson score. The outcomes collected were 30 day mortality, persistent bacteraemia [defined as positive blood culture (BC) >14 days after the first positive BC, but within 30 days], relapse (defined as recurrence of the same phenotype >30 days after the first positive BC within 12 months) and adverse events.
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The patient responded well to pharmacologic treatment and at 18-month follow-up, he is disease free.
Pneumocystis carinii pneumonia occurred in two patients with unusual clinical findings. In one case, P carinii infection was diagnosed for the first time in a patient with Crohn's disease. Due to the lack of typical features in both cases an empiric trial of antimicrobial therapy could have delayed diagnosis and initiation of specific treatment for P carinii. Contrariwise, without histologic confirmation, specific therapy for P carinii pneumonia might have been mistakenly discontinued in the second patient. Empiric therapy with trimethoprim-sulfamethoxazole may cause rapid disappearance of P carinii cysts from pulmonary tissues and cause subsequent biopsies to be falsely negative in patients who fail to respond to treatment.
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Patients with lymphoproliferative HM, specifically chronic lymphocytic leukemia and non-Hodgkin lymphoma, who are receiving fludarabine and with autoimmune disorders are at increased risk for PCP and should be considered for PCP primary prophylaxis.
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In acute pyelonephritis, bacterial resistance to co-trimoxazole predicts treatment failure, but the clonal basis of such resistance is undefined. We did molecular and serological analyses of 170 Escherichia coli urine isolates obtained in 1994-96 from women with acute pyelonephritis. 12 (7%) of the pyelonephritis isolates were in clonal group A (CGA; responsible for 38-51% of co-trimoxazole resistance in acute cystitis), including ten (34%) of 29 isolates that were resistant to co-trimoxazole. CGA isolates were obtained from diverse locations across the USA and were related to the O15:K52:H1 clone of the 1986-87 outbreak in London, UK. Thus, CGA is broadly disseminated and contributes to co-trimoxazole resistance in pyelonephritis as well as in cystitis.
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Proportion of diarrhoea-free days in the 7 days following treatment, as determined by daily stool counts.
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Here, we describe a patient with disseminated systemic nocardiosis. He had a history of systemic lupus erythematosus and had received oral prednisolone for 7 months. Nocardia farcinica was isolated from the pus. There were neither clinical nor radiologic features of pulmonary nocardiosis. The patient was treated with oral trimethoprim/sulfamethoxazole, intravenous imipenem and surgical drainage with a good clinical response, and there has been no recurrence of the infection.
HIV-associated infections in sub-Saharan Africa differ markedly in their incidence from those in industrialized countries. Tuberculosis is the commonest cause of morbidity and mortality. Enteric pathogens such as microsporidiosis commonly cause disease as access to safe water is limited. Pneumocystis carinii pneumonia, which is the commonest opportunistic infection in industrialized countries, is uncommon in adults with HIV infection. This remains unexplained because P. carinii pneumonia is common in Black African HIV-infected children. Cytomegalovirus and Mycobacterium avium complex, which only occur in severely immune-suppressed individuals, are seldom found. One reason may be that survival after conversion to AIDS is relatively short in Africa. Patients often die before they develop severe immune suppression. Recently, prophylactic cotrimoxazole treatment was shown to be effective in symptomatic HIV-infected adults in Africa. Tuberculosis preventive therapy is also effective in Africa, at least in the medium term. It is hoped that these two affordable interventions will become available to large numbers of patients identified in voluntary counselling and testing centres.
Three patients with culture-proven MRSA laryngitis were identified. Three further cases of MSSA were also identified. Patients ranged in age from 34 to 74 years. All three patients with MRSA were diabetics. All six patients in the study were current or past users of cigarettes. The most common presenting symptoms were vocal roughness, vocal fatigue, and decreased vocal endurance. There were no symptoms of airway or swallowing compromise. The duration of symptoms at the time of initial assessment ranged from 3 months to 5 years, and most patients had undergone numerous previous treatments. Common signs on laryngeal examination included thickened vocal fold epithelium, whitish debris or the appearance of leukoplakia, edema, and crusting. Signs and symptoms were similar in MRSA and MSSA patients. The diagnosis was made in all patients via awake in-office culture of the larynx. All patients were treated with a prolonged course of trimethoprim-sulfamethoxazole (2-4 weeks). Although repeated courses of treatment were required, most patients had an excellent response to treatment.
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Pneumocystis jiroveci (PJ) infection is rare in infants and is suggestive of primary or secondary immunodeficiency. We report on a case of severe PJ pneumonia in an immunocompetent infant after prolonged corticosteroid treatment.
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There were 92 (23%) therapy failures in the co-trimoxazole group and 30 (15%) in the amoxycillin group (p=0.03)-26 (13%) versus 12 (12%) among children with non-severe pneumonia (p=0.856) and 66 (33%) versus 18 (18%) among those with severe pneumonia (p=0.009). For patients with severe pneumonia, age under 1 year (p=0.056) and positive chest radiographs (p=0.005) also predicted therapy failure. There was no significant association between antimicrobial minimum inhibitory concentration and outcome among bacteraemic children treated with co-trimoxazole.