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Two patients with acute endocarditis attributable to Staphylococcus aureus had a clinical syndrome similar to meningococcemia with meningitis. That fulminant S aureus septicemia may on occasion be associated with hemorrhagic skin lesions, thrombocytopenia, coagulation abnormalities, and meningitis is emphasized.

The activity of teichomycin A2 was compared with that of vancomycin in vitro against clinical isolates of staphylococci and enterococci. Teichomycin A2 was more active than vancomycin active against all isolates tested. Synergistic studies also demonstrated that teichomycin A2 combined with rifampin is more active than vancomycin combined with rifampin against Staphylococcus aureus and Staphylococcus epidermidis isolates. Teichomycin A2, either singly or in combination with an aminoglycoside, was more active against Streptococcus faecalis isolates.

Eight patients with serious staphylococcal infections such as endocarditis, meningitis, epidural abscess, shunt and graft infections were treated with nafcillin, cephalothin or vancomycin in combination with rifampin. In vitro antibiotic sensitivities demonstrated that the Staphylococcus aureus and Staphylococcus epidermidis were highly sensitive to rifampin with minimum inhibitory and bactericidal levels of .0078-.25 micrograms/ml. In all patients reviewed and reported, when serum bactericidal levels were measured before and after the addition of rifampin, there was a positive correlation between microbiological and clinical outcome. Thus, in selected patients with life-threatening infections caused by S. aureus and S. epidermidis rifampin should be considered an adjunctive therapy.

An adult drug abuser with endocarditis due to a group II Staphylococcus aureus developed the staphylococcal scalded skin syndrome (SSSS). Studies of the patient's immune function found cell-mediated immunity (CMI) to be essentially normal; thus, previous suggestions that deficient CMI is required in adults who develop SSSS seem unfounded. Pathogenesis, diagnosis, and therapy of SSSS and its differentiation from drug-induced hypersensitivity reaction are discussed in detail.

In vitro studies have shown that trimetrexate, a lipid-soluble analogue of methotrexate, is 1500 times more potent than trimethoprim as an inhibitor of dihydrofolate reductase from Pneumocystis carinii. Furthermore, trimetrexate is readily taken up by P carinii, while performed folates such as leucovorin are not. These observations suggest that the combination of trimetrexate plus leucovorin, which can specifically protect mammalian host tissues from the toxic effects of the antifolate, may be useful in the treatment of pneumocystis pneumonia. This concept was tested in a clinical study of 49 patients with acquired immunodeficiency syndrome (AIDS) and P carinii pneumonia who were treated for 21 days with trimetrexate and leucovorin. Patients were divided into three groups: 16 patients who were unable to tolerate or had failed both pentamidine isethionate and trimethoprim-sulfamethoxazole therapy were treated with trimetrexate plus leucovorin (Group I); 16 patients who were unable to tolerate sulfonamide therapy were treated with trimetrexate with leucovorin as initial therapy (Group II); and 17 patients in whom trimetrexate with leucovorin plus sulfadiazine was used as initial therapy (Group III). Response and survival rates were 69% and 69% in Group I; 63% and 88%, respectively, in Group II; and 71% and 76%, respectively, in Group III. Toxicity was minimal. The results indicate that trimetrexate with leucovorin is safe and effective for initial therapy in AIDS patients with P carinii pneumonia and in those intolerant or unresponsive to standard therapies.

Three patients with serious infections due to beta hemolytic streptococci, Lancefield group G are presented. The clinical syndromes are septicemia with possible endocarditis in a patient with laryngeal carcinoma, septic arthritis in a healthy boy and endocariditis in an adult with no previous underlying valvular disease. All were treated with intravenous penicillin and recovered. The clinical and microbiologic significance of recognizing the organism is emphasized.

Forty-eight patients with 51 episodes of infective endocarditis caused by streptococci were studied in a comparison of the efficacy of single antibiotic therapy versus that of combination therapy. There was no statistical difference in terms of clinical course, toxicity, and mortality between the group given a single drug and that given combination therapy. However, one patient experienced two relapses, in both instances after high-dose penicillin therapy. The species and antibiotic susceptibilities of the infecting organisms were determined. The majority of isolates were alpha-hemolytic, with Streptococcus sanguis recovered most commonly. Streptococcus bovis and group B beta-hemolytic streptococci were the next most frequent isolates.