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A previously undescribed chronic diarrhea syndrome affected 122 residents of Brainerd, Minn, between December 1983 and July 1984. The illness lasted at least one year for 75% of case-patients and was characterized by acute onset, marked urgency, a lack of systemic symptoms, and a failure of response to antimicrobial agents. Clinical and laboratory data indicate that the diarrhea was caused by a secretory mechanism. Consumption of raw milk from a single dairy was associated with illness (odds ratio, 28.3; 95% confidence interval, 9.0 to 89.0). A median incubation period of 15 days was determined for seven case-patients. Possible secondary transmission was noted in one family. Extensive laboratory examination did not identify an etiologic agent. Outbreaks or sporadic cases of a similar illness have occurred in at least seven states; the outbreaks were less extensively investigated and findings were not published, but raw milk consumption was common in the affected persons. This illness appears to represent a previously unrecognized but important clinical entity and public health problem. The etiology and effective therapy for this illness must be determined by further studies of sporadic cases and outbreaks.
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Trimethoprim-sulfamethoxazole (TMP-SMX) is an antimicrobial drug combination commonly prescribed in children and adults. The study objectives were to validate and apply an HPLC-MS/MS method to quantify TMP-SMX in dried plasma spots (DPS) and dried urine spots (DUS), and perform a comparability analysis with liquid matrices.
Data from 1459 children were analysed: 725 were randomised to amoxicillin and 734 to co-trimoxazole. Treatment failure in the amoxicillin group was 16.1% compared to 18.9% in the co-trimoxazole group. Multivariate analysis showed that treatment failure was more likely in infants who had history of difficult breathing or those who had been ill for more than three days before presentation.
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This case report documents a case of IVIG-responsive DITP initially misdiagnosed as PTP, highlighting the clinical overlap of these immunologic-mediated phenomena.
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Several prospectively randomized trials have shown that the administration of prophylactic oral nonabsorbable antibiotics may be beneficial in decreasing the incidence of infection in granulocytopenic patients, whereas others have not. Intolerable nausea and vomiting have prevented the prolonged use of these agents in some studies. Discontinuation of therapy while patients are still granulocytopenic has carried the risk of life-threatening infections, often with aminoglycoside-resistant gram-negative organisms. The benefit of selective decontamination with trimethoprim/sulfamethoxazole used prophylactically remains controversial. The use of trimethoprim/sulfamethoxazole may also be associated with the development of resistant, potentially pathogenic, organisms or prolonged neutropenia. These regimens do not appear to be indicated when patients are anticipated to be neutropenic for less than three weeks. Even in patients with prolonged neutropenia, the risks of such treatment must be weighed against potential benefits.
Nocardiosis is an opportunistic infection especially in immunocompromised patients. Lungs are the most common infection sites and therapy poses some difficulties. We describe a case of pulmonary infection with Nocardia asteroides in a non-Hodgkin's lymphoma patient. Although the mortality from pulmonary nocardiosis is high in immunocompromised patients, our patient was successfully treated with trimethoprim-sulfamethoxazole (TMP/SMZ) and amikacin. Maintenance therapy with TMP/SMZ was continued for 1 year. This case supports the importance of the long-term maintenance treatment after the initial combination therapy.
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Sulfonamide antibiotics are not effective for the treatment of Rocky Mountain spotted fever (RMSF). Patients suspected of having RMSF based on history and physical exam should be treated with doxycycline and not a sulfonamide to avoid increased morbidity and mortality.
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Seven cases of visceral leishmaniasis are reported, whose epidemiologic, clinical, laboratory, evolutive and therapeutical features are presented. Latest findings are described with reference to laboratory tests and new recent possibilities of therapy.
We retrospectively studied all courses of treatment with trimethoprim-sulfamethoxazole (TMP-SMZ) alone and with adjuvant corticosteroids for AIDS-associated Pneumocystis carinii pneumonia. The corticosteroids were administered for 8-21 days (mean, 14 days) because of hypoxemia. We evaluated the influence of corticosteroids on the incidence of cutaneous adverse reactions to TMP-SMZ and on the course of AIDS during 3 months of follow-up. Of 38 patients treated with TMP-SMZ alone, 18 (47%) developed cutaneous side effects, whereas three (13%) of the 23 patients who received adjuvant corticosteroid therapy experienced such effects (P = .014). Of the 21 reactive patients, 14 were treated throughout the duration of hypersensitivity. Therapy was interrupted for seven patients (18%) treated with TMP-SMZ alone and for none of those who were given adjuvant corticosteroid therapy (P = .23). During follow-up, the incidence of mucocutaneous herpes simplex virus infection was higher among patients who received adjuvant corticosteroids than among those treated with TMP-SMZ alone (P = .005). Adjuvant corticosteroids thus reduce the incidence of adverse cutaneous reactions to TMP-SMZ in patients with AIDS who are treated for hypoxemic P. carinii pneumonia.
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For many years now, the combination trimethoprim plus sulfamethoxazole (active ingredients of Bactrim) has proved to be an effective chemotherapeutic agent with a broad spectrum of antibacterial activity against both gram-positive and gram-negative organisms, including beta-hemolytic streptococci, staphylococci, pneumococci, Haemophilus influenza, Escherichia coli, Proteus mirabilis, Proteus vulgaris, Klebsiella, Enterobacter and Citrobacter. In this comparative study, the antibacterial activity of the combination against 2,229 gram-negative and 1,338 gram-positive strains encountered in domiciliary practice was tested and compared with that of other commonly used antimicrobials. Minimum inhibitory concentrations (MICs) were determined in microtitre plates using serial dilutions. With regard to the gram-negative strains, trimethoprim + sulfamethoxazole, with an MIC90 of less than 2 mg/l for most isolates, was the most active substance apart from norfloxacin. The combination also had a powerful inhibitory effect on gram-positive strains, the MIC90 being between 2 and 4 mg/l for all strains except Staphylococcus epidermidis.
Since the end of the 1980s, primary anti-Pneumocystis carinii pneumonia (PCP) prophylaxis has become a fundamental part of the global AIDS control strategy in industrialized countries. The widespread adoption of anti-PCP chemoprophylaxis has been a key element in prolonging the survival of patients with AIDS. There is general agreement on the need to begin chemoprophylaxis when individual CD4+ cell counts drop below the value of 200/microL. However, PCP still develops in up to 27% of susceptible HIV-infected patients despite regular prophylaxis intake. Failure of chemoprophylaxis may depend on different factors. The choice of the regimen and the patient's compliance to it have been the first variables to be identified, whereas the importance of the residual cellular immune function as complementary protective mechanism against PCP has emerged in subsequent clinical studies. Albeit of limited general concern, issues such as P. carinii drug resistance and defective drug absorption may play some role in prophylaxis failure in selected patients. Regarding the epidemiology of primary and recurrent episodes of PCP, recent studies based on genetic fingerprinting techniques revealed that interhuman transmission of the organism could be more relevant than so far expected, thus raising some concern of the possibility of nosocomial spread among susceptible individuals. The downgrading tendency of immune competence in HIV infection and the related increasing risk of developing PCP make it possible to envisage a two-step chemoprophylactic strategy, with the most effective compound, cotrimoxazole, to be reserved for the last and most risky disease stage, when immune response no longer provides any support for preventing the development of PCP.