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Clinicians caring for patients with vancomycin-resistant Enterococcus faecium (VREF) infections face severe constraints in the selection of treatment. Quinupristin/dalfopristin (Synercid) is active in vitro against VREF, with a MIC(90) of 1.0 microg/mL. We investigated the clinical efficacy and safety of this agent in a multicenter, prospective, noncomparative, emergency-use study of 396 patients. Patients were included if they had signs and symptoms of active infection, including bacteremia of unknown origin, intra-abdominal infection, and skin and skin-structure infection, with no alternative antibiotic therapy available. The mean duration of treatment was 20 days (range, 4-40 days). The clinical response rate was 68.8% in the evaluable subset, and the overall response rate was 65.6%. The most common adverse events related to quinupristin/dalfopristin were arthralgias and myalgias. Related laboratory abnormalities were rare. In this severely ill patient population, quinupristin/dalfopristin was efficacious and demonstrated an acceptable safety profile in the treatment of VREF infection.

Because dialyzers with removable headers and O-rings are widely used in patients receiving long-term hemodialysis, disinfection procedures should include measures to ensure adequate disinfection of O-rings.

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Resistance to antimicrobial agents is an evolving process, driven by the selective pressure of heavy antibiotic use in individuals living in close proximity to others. The intensive care unit (ICU), crowded with debilitated patients who are receiving broad-spectrum antibiotics and being cared for by busy physicians, nurses, and technicians, serves as an ideal environment for the emergence of antibiotic resistance. Problem pathogens presently include multiply resistant gram-negative bacilli, methicillin-resistant Staphylococcus aureus, and the recently emerged vancomycin-resistant enterococci. The prevention of antimicrobial resistance in ICUs should focus on recognition via routine unit-based surveillance, improved compliance with handwashing and barrier precautions, and antibiotic-use policies tailored to individual units within hospitals.

Resistance to antimicrobial agents is an evolving process, driven by the selective pressure of heavy antibiotic use in individuals living in close proximity to others. The intensive care unit (ICU), crowded with debilitated patients who are receiving broad-spectrum antibiotics and being cared for by busy physicians, nurses, and technicians, serves as an ideal environment for the emergence of antibiotic resistance. Problem pathogens presently include multiply resistant gram-negative bacilli, methicillin-resistant Staphylococcus aureus, and the recently emerged vancomycin-resistant enterococci. The prevention of antimicrobial resistance in ICUs should focus on recognition via routine unit-based surveillance, improved compliance with handwashing and barrier precautions, and antibiotic-use policies tailored to individual units within hospitals.

Legionellae are Gram-negative bacteria which are capable of causing disease, most commonly in the form of pneumonia. We describe a case of native valve endocarditis caused by a Legionella strain which by genotypic (16S rRNA and mip gene sequencing) and phenotypic analyses is unlike previously described strains of Legionella.Of the 54 validly named Legionella species, 21 have been isolated from human infections (14,24). Legionella pneumophila represents 90% of the cases, with L. longbeachae and L. bozemanae being the next most common, causing 4% and 2% of cases, respectively (25). The primary site for Legionella infection is the lung, but in rare cases, Legionella is found in extrapulmonary sites, either as a consequence of dissemination from the lung or as isolated primary infections (13). Here, we describe an unusual case of Legionella endocarditis in a native heart valve. Genotypic and phenotypic analyses indicate that the bacterial isolate is unlike previously described strains of Legionella.A 68-year-old woman with Goodpasture's syndrome who underwent living related kidney transplantation in 2004 presented to the hospital in August 2009 complaining of chest pain and dyspnea on exertion. Her history was notable for cytomegalovirus viremia in 2004 and an episode of organ rejection in 2008 requiring methylprednisolone and thymoglobulin therapy. Her maintenance immune suppression was mycophenolic acid and tacrolimus. At presentation, she reported a 1-day history of chest pain associated with nausea, diaphoresis, and anxiety. She was afebrile, with a heart rate of 100 bpm, blood pressure 113/42 mm Hg, and pulse oximetry of 96% on 2 liters of oxygen. A grade II holosystolic murmur was present. Her leukocyte count was 13,500/mm 3 (normal range, 4.1 to 10.9/ mm 3 ), creatinine level was 3.5 mg/dl (normal range, 0.4 to 1.0 mg/dl), potassium level was 5.7 meq/liter (normal range, 3.4 to 5.1 meq/liter), and troponin level was 0.2 ng/ml (normal range, Յ0.1 ng/ml). A chest radiograph demonstrated an infiltrate in the right lower lobe, which was confirmed by computed tomography (CT) scan of the chest.Due to a history of penicillin allergy, vancomycin and ciprofloxacin were initiated for suspected health care-associated pneumonia (she had been hospitalized 3 weeks earlier for "gastroenteritis"). L. pneumophila urine antigen and urine pneumococcal antigen were undetectable, and blood cultures revealed no growth. Her troponin level continued to rise and peaked at 2.18 ng/ml. A transesophageal echocardiogram showed a 1.09-cm freely mobile mass on the left coronary cusp of the aortic valve, consistent with vegetation.Vancomycin and ciprofloxacin were continued, and gentamicin was added for empirical coverage of culture-negative endocarditis. Her clinical status deteriorated, and she underwent emergency aortic valve replacement with a bovine bioprosthesis on the 6th day of hospitalization. Intraoperative findings included a trileaflet aortic valve with a large vegetation on the left coronary cusp. No aortic annulus abscess was ...