Dosages of micafungin 100 mg daily and 150 mg daily were noninferior to a standard dosage of caspofungin for the treatment of candidemia and other forms of invasive candidiasis.

The erm gene product confers clindamycin resistance on Staphylococcus aureus. We report a clindamycin clinical failure where resistance developed on therapy in a D-test-positive strain. D tests of 91 clindamycinsusceptible, erythromycin-resistant S. aureus isolates showed that 68% of methicillin-susceptible and 12.3% of methicillin-resistant S. aureus strains were D-test positive.Clindamycin-susceptible, erythromycin-resistant Staphylococcus aureus (clindamycin-erythromycin discordant) may develop clindamycin resistance (7,8). The erm gene product is a ribosome methylase whose expression is normally minimal. Erythromycin induces the production of this methylase, which is why these strains are erythromycin resistant, but mutations in the promoter region of erm allow production of methylase without an inducer (18,19). These mutants are stably erythromycin and clindamycin resistant. Since erythromycin resistance can occur with other mechanisms (e.g., efflux pumps and enzymatic modification) (15), the D-test identifies inducible resistance that might presage mutational clindamycin constitutive resistance. The D-test is performed by placing clindamycin and erythromycin disks at an edge-to-edge distance of 15 to 20 mm and looking for flattening of the clindamycin zone nearest the erythromycin disk (2). A positive D-test suggests the presence of an erm gene that could result in constitutive clindamycin resistance and clinical failure.There are few published clinical failures of clindamycin with emergence of resistance (1,3,9,12,16). However, there are also reports of successful use of clindamycin in treating patients with D-test-positive isolates (3, 9). We report a clinical failure with documented emergence of resistance. In order to avoid poor clinical outcomes but retain the usefulness of clindamycin, it would be helpful to know the prevalence of inducible resistance in clindamycin-erythromycin discordant bacteria. This prevalence varies by geographic location, patient age, bacterial species, and bacterial susceptibility profile (4,5,10,11,13,14,16). For example, a pediatric population in Houston, Tex., with methicillin-resistant S. aureus (MRSA) had a D-test positivity rate of 2.2% (9) compared to a similar population of children with MRSA in Chicago, Ill., whose D-test positivity rate was 94% (3). We determined the prevalence of D-test positivity in clindamycin-erythromycin discordant S. aureus isolates in our institution in early 2004. We tested isolates from infected body sites where clindamycin might be considered for therapy.The patient was a 44-year-old man with fever, chills, and increased low back pain 10 days after a lumbar discectomy. At admission he had a temperature of 102.4°F and complained of 3 days of erythema, bloody drainage, and pain along his incision. He had a wound exploration, and the tissue Gram stain showed white blood cells and gram-positive cocci. Fluid and blood cultures grew clindamycin-erythromycin discordant methicillin-susceptible S. aureus (MSSA), which was treated with 2 weeks of ox...

Cerebral phaeohyphomycosis caused by Cladophialophora bantiana is a rare disease. We describe a heart and bilateral lung transplant recipient who was unsuccessfully treated for a C. bantiana brain abscess. This report compares the present case to those of other solid-organ transplant recipients with the same infection and to those of patients who did not receive transplants

Endocarditis is substantially more common in heart transplant recipients than in general populations. Frequent central venous catheter access and multiple endomyocardial biopsies appear to predispose to infection. Aspergillus is a common pathogen and endocarditis follows infection elsewhere. The prognosis of post-cardiac transplant endocarditis is poor.