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Quantitative aerobic and anaerobic cultures of deep tissue were performed on amputated infected lower limbs of 13 diabetic patients immediately after surgery. Dissection was made through intact skin distant from any preexisting ulcer. The results were compared with those obtained from: (i) ulcer swabs (pre-and postamputation), (ii) curettage of the ulcer base, and (iii) needle aspiration after normal saline injection. Anaerobic transport media were used for anaerobic cultures before prompt transfer to the anaerobic chamber. A mean of 4.7 bacterial species per specimen was seen (2.3 aerobes, 2.4 anaerobes). Mean logo growth per gram of tissue was as follows: (i) aerobes plus anaerobes = 6.99, (ii) aerobes = 6.42, and (iii) anaerobes = 7.65. There was poor concordance between the deep tissue culture results and the results from other modalities of culture collection,

Forty-three patients with spontaneous bacterial peritonitis (SBP) between 1973 and 1978 were identified. Criteria for SBP included a positive ascites culture and polymorphonuclear cell concentration greater than 250 cells per mm3. Chronic liver disease was documented by vayces in 91%, severe histologic fibrosis or cirrhosis in 94%, splenomegaly in 91%, and past hospitalization for liver disease in 57% of the patients. SBP was detected within 7 days of admission in 17 patients (40%) and within 35 days in 38 patients. Single organisms were isolated from 38 patients and multiple organisms from 5 patients. Twenty-six of 43 patients survived the episode of SBP, but only 13 survived the hospitalization. Analysis of the survival curve from the onset of SBP revealed a rapid death rate and a slow death rate set of patients. Rapid death (5 7 days from SBP onset) correlated with a lack of prior hospitalization for liver disease (p < 0.001), hepatomegaly (p < 0.001), increased serum bilirubin (p < 0.005), serum creatinine (p < 0.05), and peripheral white blood cell concentrations (p < 0.05). Survival during hospitalization was associated with prior hospitalization with liver disease (p < 0.001) and chills during the episode of SBP (p < 0.001). The 43 patients were divided into Group 1 patients on the basis of a serum bilirubin > 8 mg% and/or serum creatinine > 2.1 mg%; Group 2 patients had lower values. Survival was greater in Group 2 patients with advanced, relatively quiescent liver disease compared to Group 1 patients for both the episode of SBP (91 vs. 29%; p < 0.001) and for hospitalization (50 vs. 9%; p < 0.05). Death in Group 2 patients was related to inadequate antibiotic therapy (p < 0.05), nonhepatic factors, and new onset of renal failure. Although SBP in the setting of severe acute liver injury has a dismal prognosis, SBP with minimal acute liver injury has a relatively good prognosis for hospital survival even with advanced chronic liver disease. Long-term survival is also possible since 4 of 9 patients with prolonged follow-up have survived 3 years.Several studies (1-4) have confirmed the original observation of concerning the clinical aspects of spontaneous bacterial peritonitis (SBP) in patients with chronic liver disease. Typical findings have been: (i) severe chronic liver disease with varices; (ii) infection with a single organism (primarily Escherichia coli) with the notable paucity of anaerobes, and (iii) a high mortality. A number of potentially important factors remained unclear from these studies, including predisposing and prognostic factors. We retrospectively analyzed data from 43 patients with SBP seen at the University of Southern California Liver Unit to identify prognostic factors and plan a prospective evaluation of SBP.

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Sixteen clinical isolates of ampicillin-resistant enterococci (ARE) were recovered from the microbiology laboratory of a 450-bed rehabilitation medical center from January 1981 to September 1987. These isolates were detected when a disk diffusion test using 10 ,ug of ampicillin on a blood agar plate revealed no zones of inhibition. Tube macrodilution tests yielded an MIC of .16 ,ig of ampicillin per ml. None of the isolates were penicillinase producers by the chromogenic cephalosporin disk test. Ten isolates were Enterococcus faecium, four isolates were E. raffinosus, one isolate was E. gallinarum, and one isolate was not identified (lost). There were 6 male and 10 female patients. The sources of isolates were urine (n = 7), wound (n = 5), ascitic fluid (n = 2), blood (n = 2), peritoneal catheter tip (n = 1), Bartholin's cyst abscess (n = 1), rectal swab (n = 2), and pancreatic abscess (n = 1). The organism was isolated from multiple sites in 4 patients, was a pure culture isolate in 5 patients, and was part of a polymicrobial fora in 11 patients. Six patients were diabetic, and four had liver cirrhosis. All but four patients had received at least one antibiotic within 3 weeks of ARE isolation. The MICs (micrograms per milliliter) for 50 and 90% of isolates tested, respectively, were as follows:

Forty isolates of methicillin-resistant Staphylococcus aureus were tested for in vitro susceptibility to cephalothin, cefamandole, cefotaxime, and moxalactam, using the disk diffusion and microbroth dilution methods at incubation temperatures of 30 and 35°C. Resistance to all four antibiotics was more clearly evident at an incubation temperature of 30°C.Methicillin-resistant Staphylococcus aureus infections are being seen with increasing frequency in the United States (5,8,11,15,17). The resistance of these microorganisms to the semisynthetic penicillins has posed therapeutic problems, and clinical failures have been reported with earlier cephalosporins despite apparent in vitro susceptibility to these drugs (1,11,14).In a recent communication (7) we reported discordant in vitro disk susceptibility results for the effect of cephalothin on methicillin-resistant S. aureus when the incubation temperature was changed from 35 to 30°C. Similar observations had been reported previously with methicillin and other semisynthetic penicillins (2, 6, 16). We also showed in our study that additional isolates of methicillin-resistant S. aureus may show resistance to cephalothin by tube dilution susceptibility testing at an incubation temperature of 30°C rather than 35°C.We studied the antibiotic susceptibility of methicillin-resistant S. aureus isolated at our institution to other cephalosporins, including a second-generation cephalosporin (cefamandole) and third-generation cephalosporins (cefotaxime and moxalactam), to determine whether results similar to those of cephalothin can be observed.Forty clinical isolates of methicillin-resistant S. aureus, each from a different patient, were studied. These isolates were recovered from a variety of clinical specimens from January 1978 to April 1979. The isolates were identified by conventional methods (12).Antibiotic disk susceptibility testing was performed by the method of Bauer and associates (4) and by the agar overlay technique (3). A 30-,ug disk was used for each of the four antibiotics studied. One set of plates was incubated at 30°C and the other was incubated at 35°C for 18 to 24 h. The criteria for inhibitor zone diameter standards for cephalothin and cefamandole were obtained from previously published data (13), and those for cefotaxime and moxalactam were obtained from their respective manufacturers. These criteria are listed in Table 1.We determined minimum inhibitory concentrations (MIC) by a microbroth dilution technique in Mueller-Hinton broth (BBL Microbiology Systems, Cockeysville, Md.), using the method of Gavan and Barry (10). One set of tubes was incubated at 30°C and the other was incubated at 35°C for 18 to 24 h. All samples were run in duplicate. A known methicillinsusceptible strain of S. aureus (ATCC 25923) and a known methicillin-resistant strain from our culture collection were tested simultaneously each time the test was performed. Isolates with an MIC of 10 ,ug/ml or less were considered susceptible, and those with an MIC of 20 ,ug/ml or more were consi...