Therapy of gram positive bacteremias with presentation of four cases.

Improvement of therapeutic results in bacteremias due to the "resistant" organisms, staphylococci and enterococci, can best be achieved by a critical analysis of current concepts and adherence to certain fundamental principals. Experience with four successfully treated cases of this group of gram positive bacteremias is presented and specific therapeutic recommendations are set forth. T HE BACTEREMIAS, despite more than a decade of experience with active therapeutic agents, remain a complicated and difficult problem. The results obtained during the sulfonamide era, with only 5 to 10 per cent cures, were disappointing.' With the advent of penicillin the average cure rate of bacteremia rose to 70 per cent, where it has remained despite an increasing number of available antibiotics.2 During recent years a significant, and probably growing proportion of penicillin-resistant cases has been encountered. This aspect of the problem is largely attributable to the increased incidence of cases infected with enterococci and penicillin-resistant staphylococci. Dowling and co-workers3 have recently estimated that 300 new cases of staphylococcic endocarditis develop in the United States each year. Concurrently the ratio of Streptococcus viridans to staphylococcus endocarditis has been reported as 2.6 to 1,3 compared with the ratio of 7.4 to 1 reported by Thayer in 1926.4 In addition to this increasing incidence, both enterococcic and staphylococcic organisms have been shown to be more resistant to therapy than Streptococcus viridans. Widespread use of the newer antibiotics , such as chlortetracycline, oxytetra-cycline and chloramphenicol has not only failed to improve the situation, but has resulted in a high percentage of relapses and therapeutic failures.5 This failure of the broad spectrum antibiotics is primarily due to the fact that these agents, like the sulfonamides, 56 are mainly bacteriostatic rather than bac-tericidal. Evolving from these considerations it might be postulated that an arbitrary line is being drawn between the bacteremias which can be cured with relative ease and those where treatment failures are common. Those due to Streptococcus viridans belong to the first group, while infections due to the staphylococci and enterococci constitute the most important members of the second group. CASE REPORTS The following case reports constitute all cases of gram positive bacteremias treated on the Medical Service of this hospital over a two year period from August 1951 to August 1953.