Sparing anti-pseudomonas antibiotics in intraabdominal infections

The progress of surgery allowed the timely source control of the intraabdominal infections (IAIs); the availability and use of the broad-spectrum antibiotics resulted in an important reduction of the morbidity and mortality over the last century. Nevertheless, this pathology remains a major challenge for surgeons, internists, infectious diseases and microbiology specialists. The increased bacterial resistance and its spread within institutions limits the antibiotic treatment options and patients'outcome. This phenomenon is more obvious in Gram-negative bacilli which are the main cause of the IAIs. This paper brings into discussion the criteria which would help reducing the use of anti-pseudomonas antibiotics in the initial empirical treatment when they are not necessary, and also outlines the available therapies for these infections.

Efficacy of human simulated exposures of ceftaroline against phenotypically diverse Enterobacteriaceae isolates

Ceftaroline fosamil, a new broad-spectrum cephalosporin, exhibits potent bactericidal activity against common Gram-negative pathogens, including Enterobacteriaceae, and Gram-positive pathogens, including methicillin-resistant Staphylococcus aureus and penicillin-resistant Streptococcus pneumoniae. The purpose of this study was to evaluate the efficacy of a human simulated dose of ceftaroline fosamil against clinical Enterobacteriaceae in both neutropenic and immunocompetent mouse thigh infection models. Thirty-five Enterobacteriaceae isolates with ceftaroline MICs ranging from 0.25 to 32 μg/ml were selected for the neutropenic model, and five Escherichia coli isolates were also tested in the immunocompetent model. Two hours after inoculation, the ceftaroline fosamil human simulated regimen of 600 mg intravenously (i.v.) every 12 h was administered. The change in log(10) CFU after 24 h was compared to that in 0 h controls. The human simulated regimen produced predictable efficacy against 18 of 20 isolates with a MIC of ≤ 1 μg/ml. Similar efficacy was seen in the immunocompetent model against isolates with a MIC of ≤ 2 μg/ml, and enhanced efficacy was observed against the isolate with a MIC of 4 μg/ml. Human simulated exposures to ceftaroline fosamil at 600 mg every 12 h provided predictable efficacy against Enterobacteriaceae with MICs of ≤ 1 μg/ml and enhanced efficacy within the immunocompetent model, supporting the clinical utility of ceftaroline fosamil against these organisms.

Lymphotoxin and the amazing technicolor circus of intestinal homeostasis

Recently a new lymphocyte subset called innate lymphoid cells has emerged and it includes key producers of interleukin (IL)-17 and IL-22 in the mucosal environment. Using Citrobacter rodentium infection to deliver a pathogenic insult to the colon, two studies have revealed an underlying role for lymphotoxin-β receptor signaling in the generation of IL-22 by these cells. This observation links a system well known for its ability to organize lymphoid microenvironments into a basic mucosal response.

Acute dacryocystitis in a 2-year old child caused by pantoea

A previously healthy 23-month-old girl was admitted for the management of an acute unilateral dacryocystitis following accidental contact with dog faeces. No periocular trauma was reported. Microbiological investigation showed a multiresistant strain of Pantoea species to be the responsible pathogen. The infection responded to a course of oral Clindamycin and Ciprofloxacin, in combination with Chloramphenicol eye drops. This is the first report of an acute dacryocystitis sustained by this microorganism.

Successful treatment of a patient with sepsis and liver abscess caused by Edwardsiella tarda

Edwardsiella tarda is a bacterium that is associated with both an asymptomatic oral carrier state and self-limiting diarrhoeal illness in humans. We herein report a case of sepsis and liver abscess caused by E. tarda and review the patients with E. tarda sepsis who presented at our hospital. An 85-year-old woman developed enterocolitis and sepsis caused by E. tarda. She was administered intensive care and thus was able to soon show a good recovery, however, she subsequently developed a liver abscess. During a complicated course, she continued to be treated with antibiotics and after a successful course was discharged on the 44th day after admission.

Raoultella ornithinolytica bacteremia in cancer patients: report of three cases

Raoultella ornithinolytica is a Gram-negative aerobic bacillus reclassified in the new genus from the Klebsiella species based on new genetic approaches; however, human infections caused by R. ornithinolytica are rare. We herein report three cases of R. ornithinolytica bacteremia associated with biliary tract infections in cancer patients. R. ornithinolytica can be a causative pathogen of biliary tract infection in cancer patients.

Anthracofibrosis or anthracostenosis

Anthracofibrosis is a bronchial stenosis due to local mucosal fibrosis that also presents anthracotic pigment in the mucosa. The cause has not been well clarified, although there is a frequent association with tuberculosis and the exposure to smoke from biofuel or biomass combustion. It is an entity that has not been reported in Spain, although the influx of people from rural areas of developing countries or rural areas of our own country should make us contemplate this entity in the differential diagnosis of our patients. We present 3 cases detected in Spain (2 of them natives) diagnosed by bronchoscopy and bronchial biopsy, which are techniques necessary to confirm the diagnosis. There is no specific treatment, except for tuberculostatic treatment in cases with coexisting tuberculosis.

[Severe sepsis, septic shock and secondary multiple organ dysfunction in infection by Kluyvera ascorbata]

Kluyvera, a new genus of Enterobacteriaceae, is an emergent pathogen. Kluyvera species have been isolated from sputum, urine, stools, and blood. Kluyvera strains are infrequent but potentially dangerous pathogens in the immunocompetent or immunocompromised host due to their potential to provoke a wide range of infections and their ability to transfer extended spectrum beta lactamase genes. We herein report the case of a teenage male with severe sepsis and septic shock due to K. ascorbata.

Molecular responses of ceruloplasmin to Edwardsiella ictaluri infection and iron overload in channel catfish (Ictalurus punctatus)

Ceruloplasmin is a serum ferroxidase that carries more than 90% of the copper in plasma and has documented roles in iron homeostasis as well as antioxidative functions. In our previous studies, it has been shown that the ceruloplasmin gene is strongly up-regulated in catfish during challenge with Edwardsiella ictaluri. However, little is known about the function of this gene in teleost fish. The objective of this study, therefore, was to characterize the ceruloplasmin gene from channel catfish, determine its genomic organization, profile its patterns of tissue expression, and establish its potential for physiological antioxidant responses in catfish after bacterial infection with E. ictaluri and iron treatment. The genomic organization suggested that the catfish ceruloplasmin gene had 20 exons and 19 introns, encoding 1074 amino acids. Exon sizes of the catfish ceruloplasmin gene were close to or identical with mammalian and zebrafish homologs. Further phylogenetic analyses suggested that the gene was highly conserved through evolution. The catfish ceruloplasmin gene was mapped to both the catfish physical map and linkage map. The catfish ceruloplasmin gene was mainly expressed in liver with limited expression in other tissues, and it was significantly up-regulated in the liver after bacterial infection alone or after co-injection with bacteria and iron-dextran, while expression was not significantly induced with iron-dextran treatment alone.

Blood infection with Enterobacter aerogenes--an unusual cause of portal vein gas

Portal vein gas was once thought of as an invariably fatal condition. Now, with the availability of better equipment and expertise, the condition is more frequently diagnosed. A case of fever with rigors is presented and on ultrasound and CT examination was found to have portal venous gas which resolved with adequate antibiotic treatment. Blood culture revealed growth of gram negative bacillus; Enterobacter aerogenes. Patient was investigated further for portal vein gas, and although no other cause for the development of portal vein gas was found, she was treated with antibiotics and showed an immediate response. The aim of this case report is to highlight the benign causes of portal vein gas as well as to discuss the causes which warrant immediate surgery. Portal vein gas may herald a more ominous condition, which if intercepted in its course may result in complete cure.

[Recurrent cardiac tamponade and sepsis in a patient with rheumatoid arthritis]

Exudative pericarditis is found in 30-50% of the patients with rheumatoid arthritis (RA), particularly in later stages of the disease. Most cases present with no or few symptoms. We report a case of a 68 year-old male with a history of mild RA who developed exudative pericarditis leading to recurrent cardiac tamponade requiring repeated pericardiocenteses. Treatment with glucocorticosteroids, methotrexate and colchicine proved ineffective in preventing the recurrences. Immunosuppression contributed to the development of sepsis caused by Enterobacter cloacae and resulting in the patient's death.

Probiotics -- a viable therapeutic alternative for enteric infections especially in the developing world

This review focuses on the most recent advances in the application of probiotics as potential therapeutics for the developing world, from the treatment of chronic and acute enteric infections and their associated diarrheal complexes to the development of designer probiotics for controlling HIV and as novel mucosal vaccine delivery vehicles.

[Infected myxoma as a cause of acute infective endocarditis]

Myxoma is the most frequent primary cardiac tumor. In the typical clinical picture mostly dominate signs of intracardial obstruction, embolisation or general signs of neoplastic process. The myxoma can mimic the course of acute endocarditis. Genuine proof of infection is rare. We report on a patient with familiar form of infected myxoma, who was treated succesfully with antiobiotic therapy and surgical extirpation of the tumor.

[Septic pylephlebitis associated with Enterobacter cloacae septicemia]

Septic pylephlebitis or purulent thrombosis of the portal venous system generally results from a progressive extension of suppurated thrombophlebitis, secondary to an intrabdominal infection. Germs most often found are Escherichia coli and Streptococcus, isolation of Enterobacter cloacae is unusual. We report a particular observation of septic pylephlebitis associated with E. cloacae bacteremia, without biliary, digestive or pancreatic lesion on the CT-scan. The antibiotic sensitivity pattern of the isolated germ and the negative epidemiologic investigation pled in favour of community acquired infection. The infection resolved with antibiotics and anticoagulation, followed by total repermeation of the portal system.

Polyphasic study of plant- and clinic-associated Pantoea agglomerans strains reveals indistinguishable virulence potential

Pantoea species are ubiquitous in nature and occasionally associated with infections caused by contaminated clinical material. Hence, Pantoea agglomerans is considered as an opportunistic pathogen of humans. Since species of the genus Pantoea and closely related species of other Enterobacteriaceae genera are phenotypically very similar, many clinical isolates are misassigned into P. agglomerans based on the use of quick commercial-offered biochemical tests. Our objective was to find markers enabling discrimination between clinical and plant isolates and to assess their virulence potential. We characterized 27 Pantoea strains, including 8 P. agglomerans isolates of clinical, and 11 of plant origin by biochemical tests and genotyping, including analysis of 16S rDNA and gapA gene sequences, and pattern polymorphisms of ITS- and ERIC/REP-DNA. All data showed that no discrete evolution occurred between plant-associated and clinical P. agglomerans isolates. Based on the typing results, five clinical- and five plant-associated P. agglomerans strains representing the majority of clades were tested on a model plant and in embryonated eggs. On soybean plants P. agglomerans strains independent of their origin could develop stable epiphytic populations. Surprisingly, in the embryonated egg model there was no difference of virulence between clinical and vegetable P. agglomerans isolates. However, these strains were significantly less virulent than a phytopathogenic P. ananatis isolate. We suggest that, independent of their origin, all P. agglomerans strains might possess indistinguishable virulence potential.

Centers for Disease Control and Prevention (CDC). Cronobacter species isolation in two infants - New Mexico, 2008

Cronobacter spp. (formerly Enterobacter sakazakii) are rare causes of infant septicemia and meningitis, resulting in death in approximately 40% of cases. Since 1958, 120 cases of Cronobacter infection in infants have been reported, an average of fewer than three cases per year worldwide. Powdered infant formula (PIF), which is not sterile, has been implicated repeatedly as a vehicle of Cronobacter infection; consequently, the World Health Organization (WHO) has issued guidelines for safer preparation, handling, and storage of PIF. This report describes isolation of Cronobacter spp. in two nonhospitalized, unrelated infants (one male and one female) in New Mexico in 2008; one infant developed severe brain injury and hydrocephalus, and the other infant died. An investigation by the New Mexico Department of Health (NMDOH) determined that PIF consumption was the only known risk factor in the two cases, although the sources of the Cronobacter spp. could not be determined. Cronobacter spp. were not isolated from sealed canisters of formula associated with the two infants, and clinical isolates from the infants differed by pulsed-field gel electrophoresis (PFGE). However, a Cronobacter organism was isolated from an opened canister of formula consumed by the male infant and was indistinguishable from an isolate from his postmortem blood culture. Education of formula preparers regarding potential PIF contamination, universal adoption of WHO PIF preparation guidelines, and continued improvement of PIF manufacturing processes might help prevent Cronobacter infection among infants.

Tubo-ovarian abscess with Morganella morganii bacteremia

Tubo-ovarian abscess caused by Morganella morganii is unusual. A 54-year-old menopausal woman visited the emergency room with lower abdominal pain, vomiting, and fever for 4 days. Pelvic examination revealed lifting tenderness over the right adnexum without motion tenderness of the uterus. Pelvic sonogram revealed a cystic lesion with heterogeneous content in the right ovary. Salpingo-oophoritis was suspected. Clindamycin and gentamicin were administered intravenously after obtaining blood cultures. Laparoscopy was done because of sustained fever, and an ovarian abscess was found. Laparoscopic salpingo-oophorectomy was performed. The patient was discharged 5 days later and oral clindamycin was prescribed. However, she was readmitted due to intermittent fever. The result of blood culture obtained before surgery disclosed M. morganii, which was resistant to clindamycin and cefazolin. Her symptoms resolved after administration of intravenous flomoxef. This report highlights the fact that antimicrobial resistance of M. morganii may complicate the management and outcome of this infection.

Antibodies against recombinant heat shock proteins of 60 kDa from enterobacteria in the sera and synovial fluid of HLA-B27 positive ankylosing spondylitis patients

OBJECTIVE

To study the association of HLA-B27 with IgG antibodies to different enterobacterial HSP60s in patients with ankylosing spondylitis (AS).

METHODS

IgG antibodies to 60 kDa enterobacterial HSPs were determined by ELISA in paired samples of sera and synovial fluid from 21 HLA-B27+ ankylosing spondylitis (AS) patients; and in sera from 32 HLA-B27+ AS patients, 35 HLA-B27+ healthy relatives of AS patients, and 60 HLA-B27- healthy individuals with no family members with AS.

RESULTS

HLA-B27+ patients and healthy individuals showed significantly higher IgG antibody levels to recombinant enterobacterial HSP60s than HLA-B27- healthy controls. The levels of anti-HSP60Sf and anti-HSP60Ec antibodies correlated with disease activity and anti-HSP60Ec antibodies with male gender. No association between enterobacterial HSP60 antibody levels and disease duration was observed. All groups had lower levels of IgG antibodies to rHSP60 from Streptococcus pyogenes (rHSP60 Spy). In paired samples of sera and synovial fluid from B27+ patients, IgG antibodies to enterobacterial HSP60s were detected, but in significantly higher levels in sera than in synovial fluid. The anti-rHSPSpy IgG response in these samples was lower and similar in the three groups.

CONCLUSIONS

A correlation was found between HLA-B27 and the response to recombinat enterobacterial HSP60s. This response could be associated with disease activitir and gender in some proteins and the presence eof IgG antibodies to these proteins in synovial fluid could be associated with the inflammatory process and initiation of AS.

[Severe perioperative thrombocytosis in a patient undergoing lung resection]

Severe thrombocytosis (platelet count > 1,000,000 microL(-1)) is a rare, usually reactive, process and few perioperative cases have been reported. We describe the management of a patient who developed severe reactive thrombocytosis in the preoperative period before undergoing segmentectomy to remove a malignant nodule. A platelet count of 2,086,000 microL(-1) was observed during the first few days after surgery; we therefore started antiplatelet therapy to prevent thrombotic complications. We analyze the factors that might have contributed to the development of severe thrombocytosis in this case and discuss the different treatment options that may affect perioperative outcomes in these patients.

Pyogenic liver abscess complicating early bile duct carcinoma in the middle bile duct: a rare presentation

We describe an 83-year-old woman who developed a pyogenic liver abscess complicated with early bile duct carcinoma. After percutaneous abscess drainage, endoscopic retrograde cholangiography revealed a filling defect in the extrahepatic bile duct suggestive of a bile duct tumor. Resection of the extrahepatic bile duct with regional lymph node dissection was carried out. The resected specimen showed a polypoid tumor in the middle bile duct and histologic examination revealed well-differentiated tubular adenocarcinoma limited to the mucosal layer. These findings suggest that careful investigation of the biliary tract is necessary in patients with pyogenic liver abscess, because of the possible association of bile duct cancer.

Mucin dynamics in intestinal bacterial infection

BACKGROUND

Bacterial gastroenteritis causes morbidity and mortality in humans worldwide. Murine Citrobacter rodentium infection is a model for gastroenteritis caused by the human pathogens enteropathogenic Escherichia coli and enterohaemorrhagic E. coli. Mucin glycoproteins are the main component of the first barrier that bacteria encounter in the intestinal tract.

METHODOLOGY/PRINCIPAL FINDINGS

Using Immunohistochemistry, we investigated intestinal expression of mucins (Alcian blue/PAS, Muc1, Muc2, Muc4, Muc5AC, Muc13 and Muc3/17) in healthy and C. rodentium infected mice. The majority of the C. rodentium infected mice developed systemic infection and colitis in the mid and distal colon by day 12. C. rodentium bound to the major secreted mucin, Muc2, in vitro, and high numbers of bacteria were found in secreted MUC2 in infected animals in vivo, indicating that mucins may limit bacterial access to the epithelial surface. In the small intestine, caecum and proximal colon, the mucin expression was similar in infected and non-infected animals. In the distal colonic epithelium, all secreted and cell surface mucins decreased with the exception of the Muc1 cell surface mucin which increased after infection (p<0.05). Similarly, during human infection Salmonella St Paul, Campylobacter jejuni and Clostridium difficile induced MUC1 in the colon.

CONCLUSION

Major changes in both the cell-surface and secreted mucins occur in response to intestinal infection.

Gastric acid suppression and the risk of enteric peritonitis in peritoneal dialysis patients

OBJECTIVE

Peritonitis caused by enteric organisms in peritoneal dialysis (PD) patients is associated with greater morbidity and mortality than peritonitis with non-enteric organisms. One reported risk factor for enteric peritonitis (EP) is gastric acid suppression, with two small studies providing conflicting results. The objective of this study was to determine, using a larger patient population, whether gastric acid suppressants are associated with an increased risk of EP.

PATIENTS AND METHODS

Using a single-center case-control design, information on episodes of EP occurring between 2003 and 2006 was collected. Control episodes were all non-enteric episodes of peritonitis that occurred during the same time interval. Proton pump inhibitor (PPI) or H(2)-blocker (H(2)B) use prior to development of peritonitis was documented.

RESULTS

A total of 228 peritonitis episodes among 137 patients met inclusion criteria. In 32% of episodes, the causative organism was enteric. Gastric acid suppressant use was documented in 46% of episodes, with the majority on PPIs. Overall, gastric acid suppression was not associated with a higher EP risk (p = 0.17). In a post hoc analysis, PPIs were not associated with EP [odds ratio (OR) 1.3, 95% confidence interval (CI) 0.7-2.4; p = 0.42], whereas H(2)Bs were associated with a higher risk of EP (OR 2.9, 95% CI 1.1-7.7; p = 0.04), although the number of patients on H(2)Bs was small.

CONCLUSION

Overall, gastric acid suppression was not associated with an increased risk of peritonitis with enteric organisms. While PPI use appears to be safe for PD patients with appropriate indications, the potential risk of EP with H(2)Bs requires further investigation.

An unusual case of hyperammonemia in a 83-year-old woman

Hyperammonemia, with confusion and lethargy, developed in a 83-year-old woman during a urinary tract infection by Morganella morganii, a urea-splitting Gram-negative bacillus. In this patient, it is thought to have resulted from the production of excessive amounts of ammonia due to bacterial urease and its subsequent reabsorption into systemic circulation. The patient was treated with specific antibiotic therapy, with resolution of the urinary tract infection, progressive reduction in ammonia blood levels, and a parallel improvement in her consciousness and cognitive status.

Polybacterial pyomyositis following laparoscopic colectomy for complicated diverticulosis

We report a case of diffuse subacute muscle infection caused by enteric bacteria, diagnosed two months after laparoscopic colectomy for a sigmoid abscess and successfully treated with antibiotics alone.

Normalization of the increased translocation of endotoxin from gram negative enterobacteria (leaky gut) is accompanied by a remission of chronic fatigue syndrome

There is now evidence that chronic fatigue syndrome (CFS) is accompanied by an increased translocation of endotoxins from gram-negative enterobacteria through the gut wall, as demonstrated by increased prevalences and median values for serum IgM and IgA against the endotoxins of gram-negative enterobacteria. This condition can also be described as increased gut permeability or leaky gut and indicates intestinal mucosal dysfunction (IMD). Here we report a case of a 13 year old girl with CFS who showed very high values for serum IgM against the LPS of some enterobacteria and signs of oxidative and nitrosative stress, activation of the inflammatory response system, and IgG3 subclass deficiency. Upon treatment with specific antioxidants and a "leaky gut diet", which both aim to treat increased gut permeability, and immunoglobins intravenously, the increased translocation of the LPS of gram negative enterobacteria normalized and this normalization was accompanied by a complete remission of the CFS symptoms.

Morganella morganii sepsis with massive hemolysis

Morganella morganii is a facultative gram-negative and anaerobic rod. It may be a cause of devastating infections in neonates and immunocompromised hosts. Some bacterial infections such as Clostridium and Vibrio are associated with hemolysis. However, massive hemolysis caused by M. morganii sepsis has not yet been reported. We observed a 59-yr-old man who had chemotherapy-induced neutropenia and was found to have massive hemolysis and metabolic acidosis due to sepsis. He died 6 hr after admission in spite of aggressive treatment. Two sets of blood cultures revealed the growth of M. morganii. We report here that M. morganii sepsis can cause fatal massive hemolysis leading to death.

A prediction model for bacterial etiology in acute exacerbations of COPD

OBJECTIVES

Bacteria play a leading role in acute exacerbations of chronic obstructive pulmonary disease (COPD), but we lack predictors of bacterial etiology. We developed a prediction model for infection with gram-negative enteric bacteria (GNEB) and Pseudomonas aeruginosa.

METHODS

Clinical presentation, sputum characteristics, microbial sputum patterns, lung function and previous and concomitant medication were prospectively recorded in patients with moderate to severe exacerbation of COPD. Risk factors for a specific bacterial etiology were calculated and a prediction model developed.

RESULTS

A total of 193 patients with acute exacerbation were included. In 121 (62.6%) of them a microbial etiology could be identified, most frequently Haemophilus influenzae (32 strains), Streptococcus pneumoniae (22 strains) and P. aeruginosa (12 strains). Multivariate analysis identified severe airflow obstruction and use of systemic steroids as predictors for exacerbation due to gram-negative enteric bacilli and P. aeruginosa. A prediction model including FEV1 < 35% of predicted value, systemic steroid use and prior antibiotic therapy within preceeding 3 months had a negative predictive of 89%, being a helpful tool in excluding patients at risk of exacerbation due to gram-negative enteric bacilli and P. aeruginosa when all criteria are absent.

CONCLUSION

A simple prediction model based on three factors may identify COPD patients at low risk for exacerbations with gram-negative enteric bacilli and P. aeruginosa. Bacterial Etiology in COPD Exacerbations.

Evolution of bacterial arteritis into a mycotic aortic aneurysm

Arteritis and mycotic aneurysms have been well described for more than 100 years. The authors report a case of bacterial arteritis that presented with pneumatosis of the aortic wall and that evolved over 1 week into an infected abdominal aortic aneurysm. This case documents the rapid progression from arteritis to mycotic aneurysm, highlighting the need for close radiologic follow-up and aggressive medical and surgical management.

Syndrome de Waterhouse-Friderichsen au cours d'une péritonite à Morganella morganii et Enterococcus faecium

About fifty to sixty percent of patients with septic shock acquire acute adrenal insufficiency. This insufficiency is most often relative, but can sometimes be absolute. Bilateral adrenal haemorrhage is a rare aetiology of absolute acute adrenal insufficiency. It is classically described in patients with severe meningococcemia (purpura fulminans), who commonly present many of the risk factors associated with bilateral adrenal haemorrhage (shock, coagulation disorders, sepsis). We report a case of bilateral adrenal haemorrhage during a peritonitis complicated by a septic shock, with no coagulation disorder. This observation shows up that this bilateral adrenal haemorrhage can complicate severe sepsis of various origins, and not only severe meningococcemia. It can be suspected in face of a septic shock with an unfavourable evolution despite adequate treatment.

Invasive enteric infections in hospitalized patients with underlying strongyloidiasis

Disseminated strongyloidiasis is often associated with enteric bacterial infections. This study was undertaken to determine if enteric organisms caused extraintestinal infections in patients infected with Strongyloides stercoralis but without apparent dissemination. The medical records of hospitalized patients from central Kentucky with strongyloidiasis (1993-2003) were examined to determine the occurrence of extraintestinal infections with enteric organisms. Of 30 patients with S stercoralis, 16 had invasive infections, including sepsis, meningitis, pneumonia, peritonitis, and endocarditis caused by enteric bacteria and Candida organisms. Infections were seen in 8 (62%) of 13 patients with disseminated strongyloidiasis and 8 (47%) of 17 with disease apparently limited to the gastrointestinal tract. Fifteen patients were receiving corticosteroids or other immunosuppressive therapy. Peripheral eosinophilia was seen in only 23% (7/30). Infection with S stercoralis, even without obvious dissemination, may predispose to invasive infections caused by enteric organisms. In Strongyloides-endemic areas, patients with invasive infections caused by enteric organisms should be examined for coinfection with S stercoralis.

Enterobacter sakazakii bacteraemia with multiple splenic abscesses in a 75-year-old woman: a case report

Enterobacter sakazakii is an uncommon bacterium that is known to cause severe neonatal infection and is rare among adults. We present a peculiar case of E. sakazakii bacteraemia with multiple splenic abscesses in a 75-year-old institutionalised woman, who was successfully treated with 6 weeks of imipenem and percutaneous drainage of the abscesses.

Is there still a role for emergency cerclage in the developed world? An experience from a London district hospital

INTRODUCTION

Cervical incompetence appears to have a greater prevalence in the developing world, which possibly extends to multi-ethnic communities in the UK. Emergency cerclage has been found to have a relative degree of success in patients detected on ultrasound or presenting clinically. Our study aimed to look at the emergency cerclage outcome in the multi-ethnic population of our district hospital.

METHODS

Sixty-two cases of cervical cerclage were reviewed retrospectively from 2000 to 2006 with 16 cases being emergencies. Maternal history, presentation, operation details and outcome were recorded.

RESULTS

Of the 16 emergency cases, 8 were successful (delivery over 24 weeks gestation), 7 failed and 1 had not yet delivered. The failure rate was found to be significantly higher in the black African women (P = 0.04). Diagnosis by ultrasound as opposed to clinical presentation was associated with a better outcome (P = 0.03). The most significant determinant of outcome was the presence of coliforms on presentation, all of which failed (P = 0.007).

CONCLUSION

In this small sample of patients requiring emergency cerclage, findings are suggestive of a poor outcome in black African women, which may be related to previous obstetric history. Similarly the presence of infection especially coliforms is also associated with poor prognosis, while ultrasound diagnosis of dilating cervix rather than clinical diagnosis had a better outcome. Early screening for infection, use of prophylactic antibiotics and sonographic monitoring are likely to improve the success rate of emergency cervical cerclage.

Nosocomial meningitis caused by Enterobacteriaceae: risk factors and outcome in 18 cases in 1992-2007

Nosocomial neuroinfections due to Enterobacteriaceae represented 9.5% in our cohort of 171 cases of paediatric meningitis within last 15 years. Commonest etiologic agents was E. coli - 9 (50%) followed by Klebsiella pneumoniae - 3 (16,7%) and Enterobacter cloacae. Citrobacter freundii, Proteus mirabilis and Salmonella enteritidis (1 each). Commonest risk factors were neonatal age 13 - (72.2%), very low birth weight 5 (27.8%), craniocerebral trauma - 4 (22.2%) and neurosurgery - 5 (27.8%). All but 1 case were treated with antibiotics: 8 with III-rd and 3 with IV-th generation cephalosporins (ceftazidim, cefotaxim and cefepim) 2 with meropenem and 4 with ciprofloxacin: Nosocomial meningitis due to enterobacteriaceae was associated with significantly high mortality (29.9% vs. 15.1% in all cohort of pediatric meningitis - p<0.02).

Frequency of urinary tract infection in pediatric liver transplantation candidates

An increased frequency of infections has been reported in patients with chronic liver disease. The tendency of patients in this population to acquire UTI is not completely understood. We aimed at investigating the incidence of UTI in children with cirrhosis, before liver transplantation. Twenty-six children (9 girls, 17 boys; mean age, 7.66 +/- 5.73 yr) with chronic liver disease who had undergone liver transplantation between 2002 and 2004 were included. On admission for liver transplantation, patients were examined for presence of UTI. Serum biochemistry, complete blood cell count, urinalysis and culture, glomerular filtration rate, and abdominal ultrasonography were performed prior to liver transplantation. Ten of 26 patients (38.5%) were found to have symptomatic UTI. Urine cultures revealed E. coli in five (50%), Klebsiella pneumoniae in three (30%), Enterococcus faecalis in one (10%), and Enterobacter aeruginosa in one (10%) patient(s), respectively, as etiologic factors. The etiologies of chronic liver disease in our patients with UTI were BA in five, PFIC in three, Wilson's disease in one, and alpha-1 antitrypsin deficiency in one patient. We found a significantly greater number of UTIs in patients with biliary atresia than in those without biliary atresia (p < 0.05). The mean age of the patients with UTI was 2.75 +/- 3.49 yr, which was significantly lower than in those without UTI (9.75 +/- 4.86 yr, p < 0.05). Levels for white blood cells, thrombocytes, ALT, and alkaline phosphatase were significantly higher in patients with UTI than in those without UTI. There were no significant differences between the groups with regard to serum albumin, bilirubin, AST, GGT, BUN, or creatinine levels, glomerular filtration rate, duration of disease, and PELD scores. In patients with bacteriuria, renal USG revealed normal findings in all, but except one patient who had pelvicalyceal dilatation. Scintigraphic findings demonstrated acute pyelonephritis in six (60%) patients with UTI. VCUG demonstrated vesicoureteral reflux in two patients. In conclusion, symptomatic UTI is common in children with cirrhosis. It occurs more frequently in patients with biliary atresia than it does in patients with other types of chronic liver disease. In febrile children with chronic liver disease, UTI should be considered in the differential diagnosis.

Citrobacter rodentium infection causes iNOS-independent intestinal epithelial dysfunction in mice

Attaching-effacing bacteria are major causes of infectious diarrhea in humans worldwide. Citrobacter rodentium is an attaching-effacing enteric pathogen that causes transmissible murine colonic mucosal hyperplasia. We characterized colonic inflammation and ion transport at 3, 7, 10, 30, and 60 d after infection of C57Bl/6 mice with C. rodentium. Macroscopic damage score was significantly increased 7 and 10 d after infection. Colonic wall thickness was increased at 7, 10, 30, and 60 d. Myeloperoxidase (MPO) activity was significantly increased at 3, 7, and 10 d and returned to control levels by days 30 and 60. The expressions of inducible nitric oxide synthase and cyclooxygenase-2 were increased by C. rodentium infection. Significant reductions in the epithelial secretory response to carbachol, but not to electrical field stimulation or forskolin, were observed at 3 and 10 d of infection. Translocation of enteric bacteria into the mesenteric lymph nodes was observed 10 d following infection. There was no difference in response to infection between animals deficient in inducible nitric oxide synthase and wild-type controls. The COX-2 inhibitor rofecoxib caused decreased wall thickness and MPO activity at day 10. However, COX-2 inhibition did not alter infection-induced changes in ion transport. Citrobacter rodentium infection causes colonic inflammation, mucosal hyperplasia, and nitric-oxide-independent epithelial dysfunction in association with increased permeability to luminal bacteria.

[Microbiota of the large bowel in patients with allergic diseases]

Spectrum of microorganisms vegetated in the large bowel of patients with allergic diseases was investigated. The index of constancy C was used for characterization of the microbial population. 80 patients (31 adults and 49 children < 14 years) were examined. Most prominent changes in obligatory and facultative parts of microflora were revealed in children. Serological typing of 108 cultures of enterobacteria isolated in children under examination with disbiosis showed variety of serogroups that can testify to the presence of pathogenic variants.

Young-infant Sepsis Combined with Urinary Tract Infection Due to Hafnia alvei

Hafnia alvei infections are uncommon and occur mainly in adult patients featuring underlying illnesses. Its isolation in pediatric cases is even more unusual. We report a rare case of sepsis combined with urinary tract infection caused by H. alvei in a 39-day-old infant who did not appear to feature any underlying disease. The infant was successfully treated with ceftriaxone over a 14-day period. In this case, we want to remind clinicians that the possibility of an extraintestinal invasive infection such as bacteremia or urinary tract infection caused by H. alvei should be taken into account in young infants who feature no apparent underlying disease.

fliP influences Citrobacter koseri macrophage uptake, cytokine expression and brain abscess formation in the neonatal rat

Citrobacter koseri causes neonatal meningitis frequently complicated with multiple brain abscesses. During C. koseri central nervous system infection in the neonatal rat model, previous studies have documented many bacteria-filled macrophages within the neonatal rat brain and abscesses. Previous studies have also shown that C. koseri is taken up by, survives phagolysosomal fusion and replicates in macrophages in vitro and in vivo. In this study, in order to elucidate genetic and cellular factors contributing to C. koseri persistence, a combinatory technique of differential fluorescence induction and transposon mutagenesis was employed to isolate C. koseri genes induced while inside macrophages. Several banks of mutants were subjected to a series of enrichments to select for gfp : : transposon fusion into genes that are turned off in vitro but expressed when intracellular within macrophages. Further screening identified several mutants attenuated in their recovery from macrophages compared with the wild-type. A mutation within an Escherichia coli fliP homologue caused significant attenuation in uptake and hypervirulence in vivo, resulting in death within 24 h. Furthermore, analysis of the immunoregulatory interleukin (IL)-10/IL-12 cytokine response during infection suggested that C. koseri fliP expression may alter this response. A better understanding of the bacteria-macrophage interaction at the molecular level and its contribution to brain abscess formation will assist in developing preventative and therapeutic strategies.

Diffuse pneumocephalus in neonatal Citrobacter meningitis

Pneumocephalus, intracranial air or gas collection, associated with neonatal meningitis is extremely rare. We report the first case in the United States and the second case in the world of intracranial gas accumulation in a neonate with Citrobacter koseri meningitis. The clinical presentation was acute with pneumocephalus demonstrated by cranial sonography and computed tomography. The clinical course was fatal despite the prompt administration of antibiotics.

A rare cause of Ludwig's angina by Morganella morganii

Ludwig's angina is a rapidly spreading and potentially lethal infection involving the floor of the mouth and neck. We present a rare case of Ludwig's angina caused by an unusual microorganism, Morganella morganii, and the group D alpha-hemolytic streptococcus. To our knowledge, this is the first case of Ludwig's angina and deep neck infection caused by Morganella morganii. Adequate airway maintenance, appropriate use of antibiotics and surgical drainage resulted in survival of the patient without complications.