Search

Background: Although viral rebound follows cessation of suppressive antiretroviral therapy in chronic HIV infection, a viremic clinical syndrome has not been described., Objective: To describe a retroviral syndrome associated with cessation of effective antiretroviral therapy in chronic HIV infection., Design: Case reports., Setting: Outpatient HIV specialty clinics in Seattle, Washington, and Boston, Massachusetts., Patients: Three patients with chronic HIV infection who discontinued suppressive antiretroviral therapy., Measurements: Clinical course, plasma HIV RNA levels, and CD4 cell counts before, during, and after cessation of antiretroviral therapy., Results: Within 6 weeks after stopping antiretroviral therapy, each patient experienced a clinical illness that resembled a primary HIV syndrome. This coincided with a marked increase in HIV RNA level and, in two of three patients, a decrease in CD4 cell count. After antiretroviral therapy was restarted, each patient's symptoms rapidly resolved in association with resuppression of HIV RNA and increase in CD4 cell count or percentage., Conclusion: A retroviral rebound syndrome similar to that seen in primary HIV syndrome can occur in patients with chronic HIV infection after cessation of suppressive antiretroviral therapy.

Objective: To identify the effects of depomedroxyprogesterone acetate (DMPA) on vaginal microbial flora and epithelium., Methods: Women who desired DMPA for contraception were evaluated before and at 3 and 6 months after initiation of 150-mg DMPA injections every 3 months. At each visit, we assessed genital symptoms, vaginal signs, vaginal microflora, and histopathology by vaginal biopsies., Results: Among 38 women observed for 6 months, there was significant reduction in mean serum estradiol level (99.9 +/- 9.3 pg/mL to 26.6 +/- 1.6 pg/mL, P <.001). The number of subjects with any Lactobacillus did not change, but the number with hydrogen peroxide (H(2)O(2))-positive Lactobacillus decreased from 20% before to 12% after 6 months of DMPA (P =.005). The log concentration in colony-forming units per milliliter of vaginal fluid of H(2)O(2)-positive Lactobacillus decreased in a linear manner from 4. 0 +/- 0.6 at baseline to 2.5 +/- 0.6 after 6 months of DMPA use (P =. 006). The mean number of cell layers in the epithelium was reduced slightly from 28.1 +/- 0.7 to 25.9 +/- 0.9 (P =.05), epithelial thickness decreased from 1.02 +/- 0.04 mm to 0.89 +/- 0.05 mm (P =. 005), and the glycogen-positive thickness decreased from 0.81 +/- 0. 04 mm at baseline to 0.66 +/- 0.05 after 6 months of DMPA use (P =. 005)., Conclusion: Depomedroxyprogesterone acetate produced a systemic hypoestrogenic state associated with decreased H(2)O(2)-positive Lactobacillus colonization and slight thinning of the glycogen vaginal epithelial layer. Such changes possibly compromise the vaginal barrier to infection.

The objective of this study was to examine the effect of oral contraceptive (OC) use on vaginal discharge, epithelium, and flora. Thirty women who planned to use OC for contraception were evaluated before and 2 months after the start of OC use. At both visits, genital symptoms and exposures were assessed by questionnaire; vaginal signs were assessed by speculum examination and colposcopy; vaginal microflora was evaluated by quantitative culture; and a vaginal biopsy was obtained for histopathologic evaluation. Variables were compared between the initial visit and after 2 months of OC use. It was found that OC use did not change the gross, colposcopic, or histologic appearance of the vaginal epithelium or characteristics of vaginal or cervical discharge. Vaginal flora essentially remained unchanged after 2 months of OC use, except that a small decrease occurred in the number of subjects with > or =10(5) colony forming units/mL of H(2)O(2) producing Lactobacillus from 16 at baseline to 9 (p = 0.04) and in the total number of subjects with Ureaplasma urealyticum from 17 at baseline to 10 of 29 (p = 0.04). The results indicate minimal effect of OC use on the vaginal epithelium and vaginal and cervical discharge, and a small effect on vaginal flora.

The pathogenesis of uncomplicated urinary tract infection (UTI) is complex and influenced by many host biological and behavioural factors and by properties of the infecting uropathogens. Most uncomplicated UTIs in women are not associated with underlying functional or anatomical abnormalities of the urinary tract, whereas sexual intercourse, spermicide use, a history of recurrent UTI and recent antimicrobial chemotherapy are important risk factors. A maternal history of UTI and young age at first UTI, as well as sexual intercourse and spermicide use, are risk factors for recurrent UTI in young women. In some young healthy women, especially those with 'low UTI risk' behaviour, features of pelvic anatomy appear to be associated with UTI risk. In postmenopausal women, anatomical and functional characteristics of the genitourinary tract are more strongly associated with UTI risk than in younger women. A genetic predisposition to recurrent UTI is suggested by the association of recurrent UTI in certain age groups with the ABH blood group non-secretor phenotype, a maternal history of UTI and early age at onset of UTI. Virulence determinants of uropathogens are much more important in the normal host than in the host who has a functional or anatomical abnormality of the genitourinary tract.

The objective of this study was to examine genital tissue, vaginal fluid, and vaginal microbial flora at 3 phases of the menstrual cycle in asymptomatic women. Vaginal examinations were performed 3 times in 74 women: at the menstrual phase (days 1-5), the preovulatory phase (days 7-12), and the postovulatory phase (days 19-24). Flora of 50 women without bacterial vaginosis (BV) was analyzed separately from flora of 24 women with BV. The volume of vaginal discharge increased and the amount of cervical mucus decreased over the menstrual cycle. Among subjects without BV, the rate of recovery of any Lactobacillus changed little (range, 82% to 98%; P = .2); however, a small increase occurred in the rate of recovery of heavy (3+ to 4+ semiquantitative) growth of Lactobacillus over the menstrual cycle (P = .04). A linear decrease occurred in the rate of recovery of heavy growth of any non-Lactobacillus species, from 72% at days 1-5 to 40% at days 19-24 (P = .002). A linear decrease also occurred in the rate of recovery of Prevotella species, from 56% on days 1-5 to 28% on days 19-24 (P =. 007), while a small linear increase occurred in the rate of recovery of Bacteroides fragilis (P=.05). Among subjects with BV, the only significant change was an increase in the rate of recovery of Lactobacillus, from 33% at days 1-5 to 54% at days 19-24 (P = .008). Among all subjects, the rate of recovery of heavy growth of Lactobacillus increased over the menstrual cycle and, in contrast, the concentration of non-Lactobacillus species tended to be higher at menses, which is evidence that the vaginal flora becomes less stable at this time.

A prospective evaluation of 331 university women who were initiating use of oral contraceptive pills (OCPs), a cervical cap, diaphragm-spermicide, or other spermicidal methods was done to assess the effects of commonly used contraceptive methods on the vaginal flora. Vaginal introital cultures were performed at baseline and then weekly for 1 month. The prevalence of Escherichia coli vaginal colonization and of abnormal vaginal Gram stain scores (Nugent criteria) increased significantly among women using a cervical cap or diaphragm-spermicide but not among women using OCPs. Women with E. coli colonization were significantly more likely to have an abnormal Nugent score and an absence of lactobacilli. In a multivariate model, use of spermicidal contraception in the preceding week was associated with an abnormal Nugent score and with colonization with E. coli, Enterococcus species, and anaerobic gram-negative rods. Thus, spermicidal methods of contraception are associated with alterations of the vaginal microflora that consequently may predispose women to genitourinary infections.

Human immunodeficiency virus 1 (HIV-1) protease inhibitors have dramatically reduced the morbidity and mortality due to HIV-1 infection. However, most of these antiretrovirals are also potent inhibitors (and occasionally inducers) of hepatic and intestinal cytochrome P450 systems and, therefore, have the potential to alter the elimination of any substance that utilizes these metabolic pathways. We describe a patient infected with HIV-1 who was treated with ritonavir and saquinavir and then experienced a prolonged effect from a small dose of methylenedioxymetamphetamine (MDMA or ecstacy) and a nearly fatal reaction from a small dose of gamma-hydroxybutyrate (GHB). We also discuss the potential for HIV-1 protease inhibitors to alter the metabolism of other abusable prescribed and illicit substances.

Semen is the body fluid most commonly associated with sexual transmission of human immunodeficiency virus type-1 (HIV-1). Because the male genitourinary tract is distinct immunologically from blood, compartment-dependent factors may determine HIV-1 shedding in semen. To identify these factors, the authors obtained 411 semen and blood specimens from 149 men seen up to three times. Seminal plasma was assayed for HIV-1 RNA and semen was cocultured for HIV-1 and cytomegalovirus (CMV), which may up-regulate HIV-1 replication. The best multivariate model for predicting a positive semen HIV-1 coculture included two local urogenital factors, increased seminal polymorphonuclear cell count (odds ratio (OR) = 12.6 for each log10 increase/mL, 95% confidence interval (CI) 12.2, 134.5) and a positive CMV coculture (OR = 3.0, 95% CI 1.2, 7.7). The best multivariate model for predicting semen HIV-1 RNA included two systemic host factors, CD4+ cell counts <200/microliter (OR = 3.0, 95 percent CI 1.3, 6.9) and nucleoside antiretroviral therapy (monotherapy: OR = 0.5, 95% CI 0.3, 1.0; combination therapy: OR = 0.4, 95% CI 0.2, 0.9), and a positive CMV coculture (OR = 1.7, 95% CI 1.0, 3.0). Thus, both systemic and local genitourinary tract factors influence the risk of semen HIV-1 shedding. These findings suggest that measures of systemic virus burden alone may not predict semen infectivity reliably.

A multicenter, double-blind, randomized, placebo-controlled clinical trial was conducted to determine the safety and efficacy of thalidomide for treating esophageal aphthous ulceration in persons infected with human immunodeficiency virus (HIV). Twenty-four HIV-infected patients with biopsy-confirmed aphthous ulceration of the esophagus were randomly assigned to receive either oral thalidomide, 200 mg/day, or oral placebo daily for 4 weeks. Eight (73%) of 11 patients randomized to receive thalidomide had complete healing of aphthous ulcers at the 4-week endoscopic evaluation, compared with 3 (23%) of 13 placebo-randomized patients (odds ratio, 13.82; 95% confidence interval, 1.16-823.75; P=.033). Odynophagia and impaired eating ability caused by esophageal aphthae were improved markedly by thalidomide treatment. Adverse events among patients receiving thalidomide included somnolence (4 patients), rash (2 patients), and peripheral sensory neuropathy (3 patients). Thalidomide is effective in healing aphthous ulceration of the esophagus in patients infected with HIV.

Acute uncomplicated cystitis among young women is very common, relatively easy to diagnose, and easy to treat with short-course antimicrobial regimens. However, there is great variability among physicians in the approaches to diagnosis and management. Cystitis, therefore, lends itself well to management by clinical practice guidelines which de-emphasize costly office visits, pre-therapy urine cultures and long courses of therapy. As cystitis guidelines continue to be developed by medical care organizations, however, it is important that they be evidence based, include the participation of practicing physicians and provide a mechanism for evaluation to ensure that quality of care and patient satisfaction are not compromised.

Four hundred and fifty-two urine isolates from women with acute uncomplicated cystitis and a positive urine culture presenting to a sexually transmitted disease clinic were collected during 1989-1991, and 213 specimens were collected over 1995-1997. The predominant species was Escherichia coli, representing 68% of the isolates; others included Staphylococcus saprophyticus (8%), Group B streptococci (7%), Proteus spp. (6%), Klebsiella spp. (4%) and Enterococcus spp.(3%). More than 10% of the E. coli isolates were resistant to ampicillin, cephalothin, tetracycline and trimethoprim sulfamethoxazole (TMP SMX ) during both study periods, with the greatest increase in resistance to ampicillin and TMP/SMX between the two periods. Six hundred and four urinary tract infection isolates, including 83% E. coli, 7% S. saprophyticus, 3%, Klebsiella spp. 2% Proteus spp., 2% enterococci, 1% Enterobacter spp. and 2% other organisms, were collected from women with acute cystitis attending a university student health service during 1995. Among E. coli isolates, 25% were resistant to ampicillin, 24% to tetracycline and 11%, to TMP SMX. Resistance to fluoroquinolones was essentially absent among gram-negative pathogens. Continued evaluation of susceptibility patterns of pathogens causing acute uncomplicated cystitis to traditional as well as new antimicrobials in well defined populations is necessary to ascertain the optimal empiric therapy.

To measure the effect of trimethoprim-sulfamethoxazole (TMP-SMX) in preventing bacterial illness, Pneumocystis carinii pneumonia (PCP), and death in people with AIDS, we conducted a retrospective medical record review of 1078 persons who were observed for 3 years on average who attended nine outpatient facilities in Seattle, Washington between January 1990 and April 1996. We calculated relative risk estimates to measure the protective effect of TMP-SMX on the development of major bacterial illnesses, PCP, and death. Use of TMP-SMX decreased the risk of PCP (relative risk [RR] = 0.23; 95% confidence interval [CI], 0.14-0.36) and deaths not attributable to PCP (RR = 0.59; 95% CI, 0.47-0.73). Prevention of major bacterial illnesses of known etiology was of borderline significance (RR = 0.77; 95% CI, 0.57-1.05) and became statistically significant with the addition of patients with infections of unknown etiology (RR = 0.77; 95% CI 0.61-0.97). Use of TMP-SMX PCP prophylaxis significantly reduced the risks of death and of PCP and was associated with a trend toward reduced risk of major bacterial infections.

Background: Although trimethoprim-sulfamethoxazole is the drug of choice for the prevention of Pneumocystis carinii pneumonia, many patients cannot tolerate it and must switch to an alternative agent., Methods: We conducted a multicenter, open-label, randomized trial comparing daily atovaquone (1500-mg suspension) with daily dapsone (100 mg) for the prevention of P. carinii pneumonia among patients infected with the human immunodeficiency virus who could not tolerate trimethoprim-sulfamethoxazole. The median follow-up period was 27 months., Results: Of 1057 patients enrolled, 298 had a history of P. carinii pneumonia. P. carinii pneumonia developed in 122 of 536 patients assigned to atovaquone (15.7 cases per 100 person-years), as compared with 135 of 521 in the dapsone group (18.4 cases per 100 person-years; relative risk for atovaquone vs. dapsone, 0.85; 95 percent confidence interval, 0.67 to 1.09; P=0.20). The relative risk of death was 1.07 (95 percent confidence interval, 0.89 to 1.30; P=0.45), and the relative risk of discontinuation of the assigned medication because of adverse events was 0.94 (95 percent confidence interval, 0.74 to 1.19; P=0.59). Among the 546 patients who were receiving dapsone at base line, the relative risk of discontinuation because of adverse events was 3.78 for atovaquone as compared with dapsone (95 percent confidence interval, 2.37 to 6.01; P<0.001); among those not receiving dapsone at base line, it was 0.42 (95 percent confidence interval, 0.30 to 0.58; P<0.001)., Conclusions: Among patients who cannot tolerate trimethoprim-sulfamethoxazole, atovaquone and dapsone are similarly effective for the prevention of P. carinii pneumonia. Our results support the continuation of dapsone prophylaxis among patients who are already receiving it. However, among those not receiving dapsone, atovaquone is better tolerated and may be the preferred choice for prophylaxis against P. carinii pneumonia.

Objective: To determine the clinical and microbiologic benefit of adding amikacin to a four-drug oral regimen for treatment of disseminated Mycobacterium avium infection in HIV-infected patients., Design: A randomized, open-labeled, comparative trial., Setting: Outpatient clinics., Patients: Seventy-four patients with HIV and symptomatic bacteremic M. avium infection., Interventions: Rifampin 10 mg/kg daily, ciprofloxacin 500 mg twice daily, clofazimine 100 mg every day, and ethambutol 15 mg/kg orally daily for 24 weeks, with or without amikacin 10 mg/kg intravenously or intramuscularly 5 days weekly for the first 4 weeks., Main Outcome Measure: Clinical and microbiologic response at 4 weeks; quantitative level of bacteremia with M. avium., Results: No difference in clinical response was noted with the addition of amikacin to the four-drug oral regimen, and only 25% in either group had a complete or partial response at 4 weeks. A comparable quantitative decrease in bacteremia was noted in both treatment groups, with 16% of patients being culture-negative at 4 weeks and 38% at 12 weeks. Toxicities were mainly gastrointestinal. Amikacin was well tolerated. Median survival was 30 weeks in both groups., Conclusions: The addition of amikacin to a four-drug oral regimen of rifampin, ciprofloxacin, clofazimine, and ethambutol did not provide clinical or microbiologic benefit.

The majority of cases of acute nongonococcal urethritis (NGU) are due to causes other than infection with Chlamydia trachomatis. Pathogens implicated as causes of nonchlamydial nongonococcal urethritis (NCNGU) include Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis, and primary infection with herpes simplex virus. In a majority of cases of acute NCNGU, no pathogen can be isolated. The etiology of chronic NCNGU is unknown.

Women with recurrent urinary tract infection (UTI) often demonstrate persistent vaginal colonization with Escherichia coli. Since strains of lactobacilli that produce hydrogen peroxide inhibit the growth of E. coli, the absence of these strains may predispose to E. coli colonization and to UTI. To test this hypothesis, vaginal introital cultures were obtained from 140 women, 65 with recurrent UTI (case-patients) and 75 without (controls). Vaginal E. coli colonization was significantly more frequent in case-patients than controls (35% vs. 11%; P < .001) and in women without H2O2-positive lactobacilli than in women with (odds ratio [OR], 4.0; P = .01). Spermicide use was associated with greater risk of vaginal E. coli colonization (OR, 12.5; P < .001) and with absence of H2O2-positive lactobacilli (OR, 2.9; P = .04). The inverse association between H2O2-positive lactobacilli and vaginal E. coli colonization remained in case-patients after controlling for spermicide use (OR, 6.5; P = .02). Thus, absence of H2O2-positive lactobacilli may be important in the pathogenesis of recurrent UTI by facilitating E. coli introital colonization.

Both qualitative and quantitative virologic measurements were compared between blood and genital compartments for 128 men infected with human immunodeficiency virus type 1 (HIV-1) to address several controversial issues concerning HIV-1 shedding in semen and to obtain further information about the distribution of virus between these two compartments. Evidence for viral compartmentalization was suggested by earlier studies that noted the poor correlation between blood and seminal virus load, phenotype, and genotype. Further support for this viral compartmentalization was based on the following observations between semen and blood: lack of association between culturability of virus in semen and viral RNA level in blood, discordant distribution of viral phenotypes, discordant viral RNA levels, a weak correlation between viral RNA level in semen and CD4 cell count in blood, differences in the biologic variability of viral RNA levels, and differences in the virus load response to antiretroviral therapy.

Acute uncomplicated urinary tract infection is one of the most common problems for which young women seek medical attention and accounts for considerable morbidity and health care costs. Acute cystitis or pyelonephritis in the adult patient should be considered uncomplicated if the patient is not pregnant or elderly, if there has been no recent instrumentation or antimicrobial treatment, and if there are no known functional or anatomic abnormalities of the genitourinary tract. Most of these infections are caused by E. coli, which are susceptible to many oral antimicrobials, although resistance is increasing to some of the commonly used agents. Review of the published data suggests that a 3-day regimen is more effective than a single-dose regimen for all antimicrobials tested. Regimens with trimethoprim-sulfamethoxazole seem to be more effective than those with beta lactams, regardless of the duration. Because of increasing resistance to trimethoprim-sulfamethoxazole, an alternative regimen such as nitrofurantoin (in a 7-day regimen), a fluoroquinolone, or an oral third-generation cephalosporin may be a better empiric choice in some areas. Acute pyelonephritis caused by highly virulent uropathogens in an otherwise healthy woman may be considered an uncomplicated infection. The optimal treatment duration for acute uncomplicated pyelonephritis has not been established, but 10- to 14-day regimens are recommended. We prefer to use antimicrobials that attain high renal tissue levels, such as a fluoroquinolone, trimethoprim-sulfamethoxazole, or an aminoglycoside, for pyelonephritis. Acute uncomplicated cystitis or pyelonephritis in healthy adult men is uncommon but is generally caused by the same spectrum of uropathogens with the same antimicrobial susceptibility profile as that seen in women.

To determine the association between trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis for Pneumocystis carinii pneumonia and risk of bacterial infections in persons with AIDS, we abstracted hospital records from 6496 adult admissions to 42 hospitals in western Washington state. Of these admissions, 570 involved 637 bacterial infections diagnosed among patients who had been prescribed prophylactic TMP-SMX or aerosolized pentamidine. Cases [admissions with bacteraemia, bacterial pneumonia, acute or chronic sinusitis, or urinary tract infection (UTI)] were compared to controls (admissions not associated with any of the 5 bacterial infections). After adjusting for CD4 lymphocyte count and presence of P. carinii pneumonia, TMP-SMX prophylaxis, relative to aerosolized pentamidine prophylaxis, was associated with a reduced risk of bacteraemia (adjusted OR = 0.5; 95% CI, 0.2-1.0; P = 0.04), bacterial pneumonia (adjusted OR = 0.5; 95% CI, 0.3-0.8; P = 0.01), acute sinusitis (adjusted OR = 0.5; 95% CI, 0.2-1.3; P = 0.2), chronic sinusitis (adjusted OR = 0.3; 95% CI, 0.1-0.7; P = 0.01), and UTI (adjusted OR = 0.5; 95% CI, 0.2-1.2; P = 0.1), and all 5 bacterial infections combined (adjusted OR = 0.6; 95% CI, 0.5-0.8; P < 0.001).

To examine whether antecedent antimicrobial use influenced subsequent relative risk of urinary tract infection (UTI) in premenopausal women, data were analyzed from two cohorts of women observed prospectively for 6 months to determine risk factors for UTI. Using a Cox proportional hazards model to adjust for covariates, we found that 326 women in a University cohort and 425 women in a health-maintenance organization cohort were at increased risks for UTI (2.57 [95% confidence interval (CI), 1.24-5.32] and 5.83 [95% CI, 3.17-10.70], respectively) if antimicrobials had been taken during the previous 15-28 days but not during the previous 3, 7, or 14 days. The increased risks were noted both for women whose antimicrobial use was for treatment of a previous UTI and for women who received antimicrobials for other illnesses. These results suggest that recent antimicrobial use increases a woman's risk of UTI, perhaps by altering the indigenous urogenital flora and predisposing to vaginal colonization with uropathogens.

To determine the prevalence of cerebrospinal fluid abnormalities in Southeast Asian refugees with reactive serologic tests for syphilis, we evaluated 65 patients, 36 prospectively and 29 retrospectively, in a primary care clinic. Information was collected on history of treponemal infections, neurologic symptoms and signs, and total protein concentration, leukocyte count, and the VDRL test in the cerebrospinal fluid. Neurologic symptoms were reported by all patients for whom data were available. Abnormal neurologic signs were found or noted in medical records in 15 (42%) prospectively evaluated patients and 9 (64%) of 14 retrospectively evaluated patients for whom data were available. No patient had evidence of congenital or non-neurologic sequelae such as cutaneous or cardiovascular manifestations of syphilis. No patient had a positive cerebrospinal fluid VDRL test, 1 had more than 5 x 10(6) leukocytes per liter (5 leukocytes per mm3), and 6 (9%) had elevated total protein levels in the cerebrospinal fluid. Previous therapy for syphilis was not associated with lower serum VDRL reactions, neurologic symptoms and signs, or cerebrospinal fluid findings. In the absence of other indications, routine examination of the cerebrospinal fluid in seropositive Southeast Asian refugees who have nonspecific neurologic symptoms has a low yield, perhaps because of the high prevalence of yaws in this population, and may not be warranted.

Recent reports of fastidious pathogens suggest the need for special blood cultures for immunocompromised patients. Blood cultures from 45 human immunodeficiency virus (HIV)-infected patients with unexplained fever (> or = 38.0 degrees C) and CD4 counts of < 125 cells per mm3 were collected into a vacuum tube with sodium polyanetholsulfonate, an Isolator tube, and BACTEC aerobic and anaerobic bottles. Blood from the sodium polyanethosulfonate tube was inoculated into BACTEC 13A bottles, which were read weekly for 16 weeks. Isolator sediment was divided among eight agar media, including four sheep blood agar media: chocolate agar, brain heart infusion blood agar, heart infusion blood agar, and brucella blood agar. Other agar plates included Sabouraud's, buffered charcoal-yeast extract, Middlebrook 7H11 (M7H11) with hemoglobin, and M7H11 with mycobactin J. Incubation conditions included air and CO2-enriched aerobic, microaerophilic, and anaerobic atmospheres. Aerobic BACTEC broths received an acridine orange stain on day 8 and were subcultured at 2, 4, and 8 weeks. Anaerobic BACTEC bottles were subcultured at 4 weeks. All solid media, including subcultures, were incubated for 8 weeks, providing a total of 16 weeks of incubation for each specimen. Clinically significant isolates included eight Mycobacterium avium complex isolates and one each of Bartonella henselae, Bartonella quintana, Shigella flexneri, Klebsiella oxytoca, and Cryptococcus neoformans. All isolates were detected with commercially available media and, with the exception of Bartonella spp., were recovered within incubation times routinely used in most clinical laboratories.

We prospectively assessed 99 Southeast Asians for the presence of thyroid disease who were attending a primary care clinic devoted to the care of refugees. Subjects were undergoing evaluation as new patients and had no previously diagnosed thyroid abnormality. Each patient had a physical examination performed by his or her primary-care provider, was given a standardized questionnaire that focused on symptoms of thyroid disease and underwent a venipuncture for total thyroxine, triiodothyronine resin uptake and thyrotropin (TSH) concentration. Those who had an abnormal examination, calculated free thyroxine index (FT4I) or TSH level were re-examined by an endocrinologist and had repeat thyroid studies performed. Although 81% of patients reported > or = 1 symptom compatible with thyroid dysfunction, only 17% were found to have laboratory abnormalities. An abnormal FT4I and TSH level was found in 5% and 13% of subjects, respectively, but only one case of clinically significant hyperthyroidism and no cases of hypothyroidism were confirmed. TSH suppression, noted in 12% of subjects, persisted over a median follow-up of 6 months. Among seven patients with an anatomic abnormality of the thyroid, four had an abnormal FT4I or TSH. We conclude that the clinical prevalence of symptomatic thyroid dysfunction among Southeast Asians is comparable to that reported for non-Asian populations, but that the frequency of subclinical hyperthyroidism may be higher. Although symptoms suggestive of thyroid disease are common, routine screening for thyroid disease is not indicated in this study.

We prospectively evaluated 201 Southeast Asian refugees in a primary care clinic for intestinal parasites and their association with gastrointestinal symptoms. Patients completed a standardized screening questionnaire which elicited information on demographic factors and eight gastrointestinal symptoms, and stools were collected for ova and parasite examination. Although 89% had been living in the U.S.A. for more than 1 year, intestinal parasites were found in 37 (18%) patients and pathogenic parasites in 23 (11%). Among these 37 patients with intestinal parasites, seven (19%) had multiple parasites. Seven pathogenic and four nonpathogenic species were identified. Hookworm was most prevalent (4.5%), followed by Strongyloides stercoralis (2.5%) and Clonorchis sinensis (2%). Cambodians had the highest prevalence (11%) and Vietnamese and highland Laotians the lowest (0%). Intestinal parasitosis was not associated with gender or duration of residence in the U.S.A. Individual symptoms had a low positive predictive value for the presence of pathogenic parasites. This suggests that even years after immigration a substantial number of Southeast Asian refugees may benefit from screening and treatment for intestinal parasites.

Acquired rifampin resistance without preexisting isoniazid resistance is highly unusual in patients with tuberculosis. The purpose of this report is to describe and characterize that unusual pattern of acquired drug resistance in three patients with human immunodeficiency virus (HIV) infection. The patients originally had Mycobacterium tuberculosis strains that were susceptible to isoniazid and rifampin. During treatment in two patients and after completion of therapy in the remaining one, each patient developed active, rifampin-resistant, isoniazid-susceptible tuberculosis. One patient subsequently developed isoniazid resistance also. Studies on patients' M. tuberculosis isolates using IS6110 restriction fragment length polymorphism typing and rpoB gene sequencing indicated that rifampin resistance in each patient arose during therapy by an rpoB gene mutation in the original M. tuberculosis isolate. Detection of this unusual drug-resistance phenotype in three patients with HIV infection suggests that acquired rifampin resistance is somehow associated with co-infection due to HIV and tuberculosis.

To determine whether recurrent, symptomatic urinary tract infections (UTIs) in a given individual are due to the same or different strains, 71 Escherichia coli strains that caused recurrent UTIs were prospectively collected from 23 infection-prone young women and studied by chromosomal restriction fragment length polymorphism (RFLP) analysis using pulsed-field gel electrophoresis. Thirty-five strains from women with first-episode UTIs were also studied. Overall, 30 (68%) of 44 recurrent UTIs were caused by a strain previously identified in that person. In contrast, 32 of 35 strains from first-episode UTIs had unique RFLP profiles. Analysis of a subset of subjects established that the majority of recurrent UTIs were due to reinfection, not persistence of the pathogen within the urinary tract, and suggested that the colonic flora was the reservoir for these reinfecting strains.

The National Cholesterol Education Program's guidelines for the detection, evaluation, and treatment of high serum cholesterol in adults were employed in screening 155 Southeast Asian refugees in a primary care clinic in Seattle, Washington. In order to determine the need for a therapeutic intervention, information also was collected on the presence of other coronary heart disease (CHD) risk factors. Male gender (39%), cigarette smoking (27%) and hypertension (26%) were the most common CHD risk factors; diabetes mellitus, obesity, a family or prior history of CHD or cerebral/peripheral vascular disease were each noted in less than 10%. The mean serum total cholesterol was 194 mg/dl. Thirty-seven (24%) patients required further lipoprotein analysis based on cholesterol level, history of CHD and risk factors for CHD. Twenty-one (66%) of 32 patients who underwent lipoprotein analysis (14% of all patients) were candidates for a therapeutic intervention for hypercholesterolaemia. Additionally, 14 (44%) patients undergoing lipoprotein analysis had depressed high-density lipoprotein levels (< 35 mg/dl). We conclude that CHD risk factors including hypercholesterolaemia are common in Southeast Asian refugee clinic patients and that in many, a therapeutic intervention may well be justified. Southeast Asian refugees should be routinely screened for hypercholesterolaemia and other CHD risk factors in accordance with the National Cholesterol Education Program's guidelines.

Persons with spinal cord injury (SCI) have an increased risk of developing urinary tract infections. Certain structural and physiological factors, such as bladder over-distention, vesicoureteral reflux, high-pressure voiding, large post-void residuals, stones in the urinary tract, and outlet obstruction increase the risk of infection. The method of bladder drainage also influences the risk of urinary tract infection, and most persons with SCI on indwelling or intermittent catheterization develop urinary tract infection. The association of behavioral and demographic factors with the risk of urinary tract infection are less well understood. The method of specimen collection must be considered when determining the significance of bacteria. A national consensus conference sponsored by the National Institute on Disability and Rehabilitation Research defined significant bacteriuria as: > or = 10(2) colony forming units (cfu) of uropathogens per milliliter of urine in catheter specimens from persons on intermittent catheterization; > or = 10(4)cfu/mL in clean-voided specimens from catheter-free males using condom catheters; and any detectable concentration of uropathogens in indwelling catheter or suprapubic aspirate specimens. Symptomatic urinary tract infection warrants therapy, but the diagnosis is complicated by the poor sensitivity and specificity of symptoms and signs. Pyuria is generally present in persons with symptomatic urinary tract infection, although it is a nonspecific test, and its absence generally indicates the absence of symptomatic urinary tract infection. Treatment of asymptomatic bacteriuria has not been shown to be beneficial and increases the risk of development of antimicrobial-resistant uropathogens. Antibiotic prophylaxis is generally not recommended because of its unproven benefit in several studies and its association with emergence of antimicrobial resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To determine the efficacy, safety, and costs associated with four different 3-day regimens for the treatment of acute uncomplicated cystitis in women., Design: A prospective randomized trial with a cost analysis., Study Population: Women with acute cystitis attending a student health center., Interventions: Treatment with 3-day oral regimens of trimethoprim-sulfamethoxazole, 160 mg/800 mg twice daily, macrocrystalline nitrofurantoin, 100 mg four times daily, cefadroxil, 500 mg twice daily, or amoxicillin, 500 mg three times daily., Results: Six weeks after treatment, 32 (82%) of 39 women treated with trimethoprim-sulfamethoxazole were cured compared with 22 (61%) of 36 treated with nitrofurantoin (P = .04 vs trimethoprim-sulfamethoxazole), 21 (66%) of 32 treated with cefadroxil (P = .11 vs trimethoprim-sulfamethoxazole), and 28 (67%) of 42 treated with amoxicillin (P = .11 vs trimethoprim-sulfamethoxazole). Persistence of significant bacteriuria was less common with trimethoprim-sulfamethoxazole (3%) and cefadroxil (0%) compared with nitrofurantoin (16%; P = .05 vs trimethoprim-sulfamethoxazole) and amoxicillin (14%; P = .11 vs trimethoprim-sulfamethoxazole). Persistence of bacteriuria was associated with amoxicillin-resistant strains in the amoxicillin group but nitrofurantoin-susceptible strains in the nitrofurantoin group. Trimethoprim-sulfamethoxazole was more successful in eradicating Escherichia coli from rectal cultures soon after therapy and from urethral and vaginal cultures at all follow-up visits compared with the other treatment regimens. Adverse effects were reported by 16 (35%) of 46 patients receiving trimethoprim-sulfamethoxazole, 18 (43%) of 42 receiving nitrofurantoin, 12 (30%) of 40 receiving cefadroxil, and 13 (25%) of 52 receiving amoxicillin. The mean costs per patient were less with trimethoprim-sulfamethoxazole ($114) and amoxicillin ($131) compared with nitrofurantoin ($155) and cefadroxil ($155)., Conclusions: A 3-day regimen of trimethoprim-sulfamethoxazole is more effective and less expensive than 3-day regimens of nitrofurantoin, cefadroxil, or amoxicillin for treatment of uncomplicated cystitis in women. The increased efficacy of trimethoprim-sulfamethoxazole is likely related to its antimicrobial effects against E coli in the rectum, urethra, and vagina.

Objective: To study the effects of a megestrol acetate liquid formulation (800 mg/d) on body weight, body composition, caloric intake, and mental outlook in patients with the acquired immunodeficiency syndrome (AIDS) who had cachexia., Design: Twelve-week, multicenter, randomized, double-blind, placebo-controlled trial., Setting: Multiple clinical centers., Patients: 100 patients with AIDS who had weight loss of 10% or more of ideal body weight were randomly assigned to placebo (n = 48) or megestrol acetate (n = 52)., Measurements: Caloric intake, body weight, body composition, and sense of well-being., Results: Most patients receiving megestrol acetate had increased caloric intake resulting in body weight gain (mainly fat mass). From baseline to week 8, the megestrol acetate group increased their daily caloric intake by 608 calories, whereas the placebo group increased intake by 134 calories (difference, 474 calories; 95% CI, -68 to 880 calories). Body weight in the megestrol acetate group increased by 3.86 kg from baseline to week 8, although it decreased by 0.46 kg in the placebo group (difference, 4.32 kg; CI, 2.42 to 6.22 kg). At week 8 in the megestrol acetate group, patients gained 3.68 kg in fat mass and those in the placebo group lost 0.28 kg (difference, 3.96 kg; CI, 2.49 to 5.43 kg). Body water, lean mass, and patient survival were not statistically different between treatment groups. Patients treated with megestrol acetate had an increased sense of well-being when compared with patients who received placebo., Conclusions: This megestrol acetate liquid formulation is well tolerated, increases food intake, results in body weight gain, and improves the sense of well-being in cachectic patients with AIDS.

We prospectively studied 40 women over a median period of 28 weeks to ascertain the effects on vaginal microflora of sexual intercourse alone compared with sexual intercourse associated with use of a diaphragm with a spermicide (diaphragm/spermicide). Compared with no sexual intercourse, sexual intercourse with use of a diaphragm/spermicide in the preceding 3 days was strongly associated with increases in rates of vaginal colonization with uropathogenic flora, including Escherichia coli (P < .0001), other gram-negative uropathogens (P = .0045), group D streptococci (P = .014), and group B streptococci (P = .0015). Except for E. coli colonization, no such increases in rates of vaginal colonization were seen at visits preceded by sexual intercourse without use of a diaphragm/spermicide. Compared with no sexual intercourse, sexual intercourse with use of a diaphragm/spermicide in the preceding 3 days also was associated with a marked increase in rates of candidal colonization (P < .0001) and with a decrease in rates of lactobacillus colonization (P < .0001). We conclude that bacterial and fungal microflora in the vagina are strongly influenced by recent use of a diaphragm/spermicide and minimally affected by sexual intercourse alone.

As we approach 2010, the year by which we were to have eliminated TB, we find this ancient disease is making a comeback. This comeback is due to many factors, but the role of HIV infection is clearly important. HIV infection can result in changes in the pathogenesis and presentation of infection with the tubercle bacillus. Consequently, as health care providers, we must respond with changes in our usual methods of prevention, treatment, and infection control. Whereas the increase in TB is currently limited to certain geographic areas, it is likely to spread more widely. All health care providers should be aware of the changing face of TB and have a high clinical index of suspicion for this disease.

Analysis of restriction fragment length polymorphisms (RFLP) was used to investigate an increase in tuberculosis (TB) among noninstitutionalized human immunodeficiency virus (HIV)-infected persons in King County, Washington. Using the IS6110 insertion sequence, RFLP analysis was done on Mycobacterium tuberculosis isolates from 18 HIV-infected patients and 10 randomly selected patients without HIV risk factors. Six HIV-infected patients with the same M. tuberculosis strain had contact at one or more of three bars as their only common exposure. Two other HIV-infected persons, a patient and a health care worker who had close contact, had matching strains. Isolates from the 10 remaining HIV-infected patients and the 10 patients without HIV risk factors had different DNA patterns. Analysis of RFLP patterns revealed a community outbreak of TB among HIV-infected persons who had not been previously linked following conventional investigation by the health department. This technique deserves further evaluation as an epidemiologic tool in the investigation of TB.

We evaluated knowledge about prescribed medications and compliance with taking those medications in 96 South East Asian refugees of different ethnic backgrounds seen in a primary care clinic. Two hundred and thirty (88%) of 262 prescribed medications were currently being taken by the patients. Although 97% of the medications were either named or described correctly, the correct rationale for taking the medication was known for only 79% and the correct dosage regimen for only 63%. Thirty-two (33%) of the 96 patients were not taking one or more of their prescribed medications, 17 (18%) were taking one or more medications not prescribed, 5 (5%) were taking duplicate forms of the same medication, and 4 (4%) were taking a medication that had been discontinued by the clinic provider. Seventy-two (75%) patients were taking one or more medications at an incorrect dose. Only 12 (12%) patients were fully compliant with all prescribed medications. We conclude that knowledge about and compliance with medications is a major problem among South East Asian patients attending a primary care refugee clinic.

The management of sexually transmitted diseases (STDs) has reached a new level in the era of antibiotic resistance and human immunodeficiency virus infection. To date, no single antimicrobial is capable of eradicating the commonly encountered STD pathogens including Neisseria gonorrhoeae, Chlamydia trachomatis, and Treponema pallidum. Among the marketed fluoroquinolones, ciprofloxacin, ofloxacin, lomefloxacin, and enoxacin all provide excellent in vitro activity (MIC90 < 0.06 micrograms/ml) and excellent in vivo efficacy against N. gonorrhoeae, including multiply resistant isolates (penicillinase-producing N. gonorrhoeae and chromosomally mediated resistant N. gonorrhoeae). Ofloxacin is the only fluoroquinolone approved by the Food and Drug Administration for chlamydial infection. All of the quinolones lack reliable in vitro activity against Ureaplasma urealyticum, a cause of nongonococcal urethritis. Although limited data suggest the usefulness of ciprofloxacin and ofloxacin in the treatment of pelvic inflammatory disease, these drugs cannot currently be recommended for single-agent therapy. Haemophilus ducreyi infections, however, can be managed effectively with the fluoroquinolones. Although their role continues to evolve, this class of drugs cannot be used equally to treat all STDs, and notably, no quinolone to date inhibits T. pallidum.

Sera obtained for treponemal serology (VDRL) from 193 Southeast Asian refugees representing five ethnic groups seen in a primary care clinic were examined for antibodies to human T-lymphotropic virus type 1 (HTLV-1), human herpes-virus-6 (HHV-6), Epstein-Barr virus (EBV), and cytomegalovirus (CMV). The seroprevalence was highest for EBV (99%), followed in decreasing order by CMV (95%), HHV-6 (26%), and HTLV-1 (0.6%). The VDRL was positive in 15% of patients. The highest seroprevalence to HHV-6 was noted in the Chinese (33%) and the lowest in the Laotian hilltribes, the Mien and Hmong (14%). Antibody to HHV-6 was most prevalent among patients under 20 and those between 60 and 69 years of age. Differences were not found among ethnic groups in the seroprevalence of HTLV-1, EBV, or CMV.

Circulating human immunodeficiency virus (HIV) p24 antigen levels were measured in 22 AIDS patients who had detectable serum antigen at baseline after induction and maintenance therapy of foscarnet for cytomegalovirus retinitis in phase I/II multicenter trials. The HIV p24 antigen levels decreased from a baseline value of 199 +/- 236 (mean +/- SD) and 140 pg/mL (median) to 106 +/- 218 and 28 pg/mL after 14 days of foscarnet induction therapy (60 mg/kg every 8 h). During chronic foscarnet maintenance, there was a sustained decrease in mean HIV p24 antigen levels below pre-foscarnet therapy baseline concentrations for a median of 16 weeks after foscarnet induction. These results provide evidence for a sustained clinical antiretroviral effect of chronic foscarnet maintenance therapy, consistent with a recent report that foscarnet-treated AIDS patients live longer than ganciclovir-treated patients.

An outbreak of respiratory syncytial virus (RSV) infection occurred among 31 patients in a marrow transplant center over a 13-week period beginning in January 1990. RSV infection was also documented in 35 family members and employees. Of 18 patients with pneumonia, 14 (78%) died. None of 13 with upper respiratory infection died. Preengraftment patients tended to develop pneumonia more frequently than did engrafted patients. Early administration of ribavirin may have had a beneficial effect in patients with pneumonia. Antigenic and genomic analysis of 14 available isolates suggested that at least four different viral strains were responsible for the outbreak. One group of patients and 1 employee in spatial proximity were infected with the same strain and likely acquired their infections nosocomially. RSV infection in marrow transplant patients is a serious and life-threatening infection with a high mortality rate once pneumonia develops.

To determine the prevalence of use of traditional health practices among different ethnic groups of Southeast Asian refugees after their arrival in the United States, we conducted a convenience sample of 80 Cambodian, Lao, Mien, and ethnic Chinese patients (20 each) attending the University of Washington Refugee Clinic for a new or follow-up visit. Interpreters administered a questionnaire that dealt with demographics, medical complaints, traditional health practices, health beliefs, and attitudes toward Western practitioners. In all, 46 (58%) patients had used one or more traditional health practices, but the prevalence varied by ethnic group. Coining and massage were used by all groups except the Mien, whereas moxibustion and healing ceremonies were performed almost exclusively by the Mien. Traditional health practices were used for a variety of symptoms and, in 78% of reported uses, patients reported alleviation of symptoms. The use of traditional health practices is common among Southeast Asian refugees. Clinicians who care for this population should be aware of these practices because they may supersede treatments prescribed by physicians or leave cutaneous stigmata that may be confused with disease or physical abuse. Good patient care may necessitate the use or tolerance of both Western and traditional modalities in many Southeast Asian refugees.

Women with culture-proven Chlamydia trachomatis cervical infection were randomized to receive either ofloxacin (300 mg) or doxycycline (100 mg), orally twice daily for 7 days. All 56 had negative cultures 5 to 9 days after treatment. Four weeks after treatment, 26 (93%) of 28 ofloxacin-treated patients and all 22 doxycycline-treated patients were cured. We conclude that 300 mg of ofloxacin given twice daily for 7 days provides effective therapy for chlamydial infection of the cervix.

The antibacterial activity and adherence-enhancing effects of nonoxynol-9 were evaluated against vaginal and uropathogenic bacteria. Nonoxynol-9 was markedly less active against the 43 uropathogenic bacterial and yeast strains tested (MIC90, greater than 32%) than against the 26 Gardnerella vaginalis strains (MIC90, less than or equal to 0.015%) and the 53 Lactobacillus strains (MIC90, 8%) tested. Hydrogen peroxide-producing strains of Lactobacillus were more susceptible to nonoxynol-9 (MIC90, 4%) than nonproducers (MIC90, 16%). Two Escherichia coli strains that expressed type 1 fimbriae and three vaginal strains of lactobacilli adhered in significantly higher numbers to vaginal epithelial cells preincubated with 5% nonoxynol-9 than to control cells preincubated with PBS. Spermicides may provide a selective advantage in colonizing the vagina with nonoxynol-9-resistant uropathogens such as E. coli, perhaps via a reduction in vaginal lactobacilli (especially hydrogen peroxide-producing strains) and through enhancement of adherence of E. coli to epithelial cells.

The safety and efficacy of azithromycin was compared with that of penicillin V in a multicenter study of the treatment of streptococcal pharyngitis in outpatients. Patients were randomized in a 2:1 ratio to either azithromycin 500 mg once on day 1 followed by 250 mg once daily for 4 days, or penicillin V (V-Cillin K) 250 mg every 6 hours for 10 days. Two hundred and forty-two patients from 29 centers were evaluable at the 11th day after enrollment. Five of 229 (2.2%) azithromycin-treated patients were not evaluable because their enrollment isolates of group A beta-hemolytic streptococci (GABHS) were resistant to the drug. In both treatment groups, 99% of patients were clinically cured or improved. Eradication of GABHS occurred in 91% of azithromycin-treated patients compared with 96% of penicillin-treated patients (p = 0.21). Of the patients who had a recurrence of GABHS, clinical evidence of infection occurred in 3 of 13 (23%) patients who had been treated with azithromycin and in 7 of 10 (70%) patients treated with penicillin. Adverse events, generally mild to moderate gastrointestinal complaints, were significantly more common in the azithromycin-treated patients (16.6%) than in penicillin-treated patients (1.7%) (p less than 0.001). Discontinuation because of side effects occurred with similar frequency in both groups. Azithromycin appears to be a safe and effective alternative treatment for streptococcal pharyngitis in adult outpatients.

We compared the safety and efficacy of a single 400-mg dose of ofloxacin, ofloxacin (200 mg) once daily for 3 days, and trimethoprim-sulfamethoxazole (160:800 mg) twice daily for 7 days for the treatment of acute uncomplicated cystitis (urinary tract infection [UTI]) in women. At 5 weeks posttreatment, 35 (81%) of 43 patients treated with single-dose ofloxacin, 40 (89%) of 45 treated with 3 days of ofloxacin, and 41 (98%) of 42 treated with trimethoprim-sulfamethoxazole were cured (P = 0.03, single-dose ofloxacin group versus trimethoprim-sulfamethoxazole group). Retreatment for symptomatic recurrent UTI was given to 7 (16%) of 43 patients initially treated with single-dose ofloxacin, 3 (7%) of 45 patients treated with 3 days of ofloxacin, and 0 of 42 patients treated with trimethoprim-sulfamethoxazole (P = 0.01, single-dose ofloxacin group versus trimethoprim-sulfamethoxazole group). There was a trend in each of the three treatment groups toward an association between persistent or recurrent episodes of significant bacteriuria and a history of UTI in the past year and with diaphragm use. Ofloxacin was more effective than trimethoprim-sulfamethoxazole in eradicating Escherichia coli from rectal cultures during or soon after therapy, but there were no differences at later follow-up visits. Adverse effects were equally common among the three treatment groups. We conclude that single-dose ofloxacin was less effective than 7 days of trimethoprim-sulfamethoxazole for treatment of uncomplicated cystitis in women, while the 3-day ofloxacin regimen and the trimethoprim-sulfamethoxazole regimen were not significantly different in efficacy.

Acute uncomplicated UTI is one of the most common problems for which young women seek medical attention, and it accounts for considerable morbidity and health care costs. Acute cystitis is a superficial infection of the bladder mucosa, whereas pyelonephritis involves tissue invasion of the upper urinary tract. Localization tests suggest that as many as one third of episodes of acute cystitis are associated with silent upper tract involvement. Acute cystitis or pyelonephritis in the adult patient should be considered uncomplicated if the patient is not pregnant or elderly, if there has been no recent instrumentation or antimicrobial treatment, and if there are no known functional or anatomic abnormalities of the genitourinary tract. Most of these infections are caused by E. coli, which are susceptible to many oral antimicrobials. Because of the superficial nature of cystitis, single-dose and 3-day regimens have gained wide acceptance as the preferred methods of treatment. Review of the published data suggests that a 3-day regimen is more effective than a single-dose regimen for all antimicrobials tested. Regimens with trimethoprim-sulfamethoxazole appear to be more effective than those with beta-lactams, regardless of the duration. Acute pyelonephritis does not necessarily imply a complicated infection. Upper tract infection with highly virulent uropathogens in an otherwise healthy woman may be considered an uncomplicated infection. The optimal treatment duration for acute uncomplicated pyelonephritis has not been established, and 14-day regimens are often used. We prefer to use antimicrobials that attain high renal tissue levels, such as trimethoprim-sulfamethoxazole or quinolones, for pyelonephritis. Women with frequently recurring infections can be successfully managed by continuous prophylaxis, either daily or thrice-weekly, by postcoital prophylaxis, or, in compliant patients, by early self-administration of single-dose or 3-day therapy as soon as typical symptoms are noted. Our drug of choice for all these regimens is trimethoprim-sulfamethoxazole. Acute uncomplicated cystitis in adult men is very uncommon, but it is occasionally noted in homosexual men who practice insertive and intercourse or in heterosexual men whose partners have vaginal colonization with E. coli.