[Piperacillin/tazobactam--Tazocin. A penicillin-based alternative to 3rd generation cephalosporins and carbapenems]

The antibiotic piperacillin/tazobactam has recently been licensed for use in Denmark. Piperacillin/tazobactam combines a well known beta-lactam antibiotitic, piperacillin, and an inhibitor of bacterial beta-lactamase, tazobactam. The combination of piperacillin and tazobactam compared to piperacillin alone has an expanded antimicrobial spectrum, which includes Klebsiellae, Escherichia coli, and Proteus vulgaris resistant to ampicillin, as well as beta-lactamase-producing Staphylococcus aureus. As piperacillin in itself possesses antimicrobial activity against streptococci, enterococci, and Pseudomonas aeruginosa, the antimicrobial activity of piperacillin/tazobactam indicates that the combination may constitute an alternative to third generation cephalosporins and carbapenems in the treatment of complicated intra-abdominal infections infections in critically ill patients and for the empirical treatment of acute neutropenic febrile patients, as indicated by clinical studies.

Anthrax as a biological weapon, 2002: updated recommendations for management

OBJECTIVE

To review and update consensus-based recommendations for medical and public health professionals following a Bacillus anthracis attack against a civilian population.

PARTICIPANTS

The working group included 23 experts from academic medical centers, research organizations, and governmental, military, public health, and emergency management institutions and agencies.

EVIDENCE

MEDLINE databases were searched from January 1966 to January 2002, using the Medical Subject Headings anthrax, Bacillus anthracis, biological weapon, biological terrorism, biological warfare, and biowarfare. Reference review identified work published before 1966. Participants identified unpublished sources.

CONSENSUS PROCESS

The first draft synthesized the gathered information. Written comments were incorporated into subsequent drafts. The final statement incorporated all relevant evidence from the search along with consensus recommendations.

CONCLUSIONS

Specific recommendations include diagnosis of anthrax infection, indications for vaccination, therapy, postexposure prophylaxis, decontamination of the environment, and suggested research. This revised consensus statement presents new information based on the analysis of the anthrax attacks of 2001, including developments in the investigation of the anthrax attacks of 2001; important symptoms, signs, and laboratory studies; new diagnostic clues that may help future recognition of this disease; current anthrax vaccine information; updated antibiotic therapeutic considerations; and judgments about environmental surveillance and decontamination.

Major differences in the IgG subclass response to Helicobacter pylori in the first and third worlds

BACKGROUND

Studies in developed countries would suggest that the immune response to Helicobacter pylori infection is a T helper cell I predominant response. Unlike subjects from developed countries, those resident in developing countries are subject to infection with a myriad of gastrointestinal pathogens from early in life. Given that H. pylori is acquired early in life, such infections may alter the immune response to H. pylori. The aim of this study was to compare the immune response to H. pylori in subjects from developed and developing countries.

METHODS

Using a previously validated IgG subclass ELISA, the H. pylori specific IgG I/IgG2 subclass ratio (a marker of the T helper cell response) in 58 adult and 21 paediatric symptomatic H. pylori positive Sowetan subjects was compared with that in 64 Australian and 45 German symptomatic H. pylori positive subjects.

RESULTS

An IgGI predominant response (IgG1/IgG2 ratio >1) was observed in 81% of Sowetan adults and 90% of children compared with 4.7% of Australians and 4.4% of Germans. The IgG1/IgG2 ratio was significantly higher in Sowetans compared with Australians and Germans (P < 0.001). In Australian and German subjects the IgG1/IgG2 ratio was significantly higher in NUD compared with DU. No significant difference was observed between NUD and other disease states in Sowetans.

CONCLUSIONS

This study is the first to provide evidence that the host immune response to H. pylori infection in an African population differs to that observed in subjects from developed countries. Further studies are required to determine if this occurs in other developing countries.

Infections in the elderly: Part 3

The number of elderly individuals is rapidly growing. As a result, more emergency transports will involve the care of an elderly patient. Distinguishing the cause of symptoms can be difficult for healthcare professionals, including emergency personnel. Clinical symptoms of infection may be absent, or not as obvious as with a younger individual. The aging process of the immune system results in the inability to fight off many infections. Transport of patients with antibiotic-resistant organisms has caused many challenges for emergency care personnel surrounding infection control practices.

Helicobacter pylori infection in Turkish children with gastrointestinal symptoms and evaluation of serology

Helicobacter pylori infection is a common etiopathogenetic factor in children with gastrointestinal symptoms in the developing world. Although serology offers an easy noninvasive method of diagnosis, its sensitivity and specificity are reported to be low among children. In this prospective study, we investigated the frequency and endoscopical and morphological findings of H. pylori infection in 180 Turkish children who underwent upper gastrointestinal endoscopy either for peptic symptoms or on a routine basis and in asymptomatic pediatric patients who underwent endoscopy for other reasons, and then evaluated the diagnostic accuracy of serology in our population. Overall H. pylori infection was diagnosed in 77 of the 180 patients (42.7%) by histology and urease test. The sensitivity of H. pylori specific IgG antibody assay by ELISA was determined to be 100%, while the specificity was 98%, the positive predictive value 97.4%, the negative predictive value 100%. Frequency of H. pylori infection is high in Turkish pediatric patients without gastrointestinal symptoms as well as in children with gastrointestinal complaints. H. pylori specific antibody assay is a noninvasive and sensitive method for the diagnosis of H. pylori infection in the Turkish pediatric population.

Helicobacter pylori infection is not associated with delayed gastric emptying or upper gastrointestinal symptoms in diabetes mellitus

This study evaluated the relationship between gastric emptying and upper gastrointestinal symptoms with H. pylori status in patients with diabetes mellitus. Sixty-three outpatients (44 type 1, 19 type 2, age 45 +/- 1.5 years) underwent measurements of gastric emptying of a mixed solid and liquid meal, gastrointestinal symptoms (gastric and esophageal), glycemic control (HbA1c), and autonomic nerve function. Anti-H. pylori IgG antibodies were quantified using a validated kit. Gastric emptying of solid and/or liquid was delayed in 47 (75%) patients, and 31 (49%) had autonomic neuropathy. Fifteen (24%) of the patients were H. pylori positive. There were no differences in gastric emptying (solid retention at 100 min: 67.5 +/- 5.7% vs 63.2 +/- 3.6%; P = 0.63, liquid T50: 35.5 +/- 2.9 min vs 42.5 +/- 3.4 min; P = 0.42), upper gastrointestinal symptoms (gastric 3.9 +/- 0.7 vs 4.0 +/- 0.4; P = 0.94 or esophageal 1.7 +/- 0.5 vs 1.3 +/- 0.2; P = 0.42) or HbA1c (8.8 +/- 0.4% vs 8.6 +/- 0.2%; P = 0.89) between H. pylori-positive and -negative patients. We conclude that H. pylori infection is not associated with delayed gastric emptying or upper gastrointestinal symptoms in diabetes.

Review article: natural history and epidemiology of Helicobacter pylori infection

Helicobacter pylori is a common bacterium infecting about half the world's population. It is causally linked with a diverse spectrum of gastrointestinal clinical disorders including peptic ulcer disease, gastric cancer, and gastric MALT lymphoma. The principal reservoir is the human stomach, and transmission probably occurs by person-to-person passage. Prevalence rates are generally much higher in developing countries compared to developed countries, although there are subgroups within many regions with higher H. pylori prevalence than in the general population. The prevalence of H. pylori varies by geographical location, ethnic background, socioeconomic conditions, and age. Recent studies suggest decreasing prevalence in developed countries or those with rapidly improving socioeconomic conditions. Comparative studies of the two fully sequenced H. pylori genomes are providing understanding of its large genetic diversity and bacterial virulence factors. The discovery of the type IV secretion system in H. pylori and its role in translocation of the CagA protein from the bacterial cell into the host epithelial cell provides insight into how host-bacterial interaction may lead to host disease. Cytokine promoter polymorphisms are determinants important in host gastric acid secretion status. Understanding the changing trends in H. pylori epidemiology, details of its transmission pathways, and the bacterial and host determinants leading to gastroduodenal disease remain the challenges in this area. Global epidemiological studies, advances in technology, and medical interventions have converged to help clarify the mechanisms of interaction between this ubiquitous micro-organism and its host that result in its diverse clinical manifestations.

Biosecurity for neonatal gastrointestinal diseases

Infectious diarrhea is an important cause of neonatal calf morbidity and mortality that results in significant economic losses in the beef and dairy industries. Although numerous risk factors related to the occurrence of neonatal diarrhea have been identified, they can all be categorized into those that are related to the calf, the pathogens involved, or the environment of the calf. The immune status of calves, specifically the level of passively acquired immunity through colostrum, is the major risk factor related to the calf and the occurrence of diarrhea. Although numerous pathogens have been implicated in the occurrence of neonatal diarrhea, only a relatively limited number are commonly involved. Most should be viewed as secondary opportunists rather than primary pathogens, because none are extraordinarily virulent, and with the exception of Salmonella spp., most are present within the gastrointestinal tract of many healthy, mature cattle. Important risk factors related to pathogens involved in neonatal calf diarrhea involve the size of the inoculum and the occurrence of multiple infections. Finally, when considering the environment and housing conditions in which beef and dairy calves may reside, it is clear that tremendous variations exist. Despite these variations, the risk factors associated with the environment of the calf are also those that are the most amenable to the implementation of general environmental control and monitoring strategies as well as specific biosecurity measures.

Open-label, multicentre, emergency-use study of clinafloxacin (CI-960) in the treatment of patients with serious life-threatening infections

In an open-label emergency-use study, 23 patients with bacterial infections caused by multiply drug resistant pathogens were treated with clinafloxacin. Efficacy and safety were evaluated by tabulating investigators' assessments at the end of treatment, treatment discontinuations and adverse event data. Most of the patients were seriously ill and had multi-organ infections, primarily respiratory tract infections such as nosocomial pneumonia and gastrointestinal infections. Eleven patients were successfully treated, two had treatment failure and 10 were not evaluable because the patients died of their underlying disease. Considering that most of the patients had several infections caused by multiply resistant pathogens, clinafloxacin may be useful for the treatment of such life-threatening episodes.

Biosecurity for gastrointestinal diseases of adult dairy cattle

As biosecurity management strategies are developed and implemented to prevent introduction and spread of infectious diseases in cattle populations, it is informative to review principles of biosecurity from another livestock species in which these issues have been considered (e.g., swine) and compare these perspectives to the current situation for cattle. The authors follow a biosecurity risk-assessment model to identify important health hazards, evaluate risks, and present principles for implementing a cattle biosecurity program for important gastrointestinal health hazards of adult dairy cattle, after consideration of a swine biosecurity model.

The non-H pylori helicobacters: their expanding role in gastrointestinal and systemic diseases

The number of species in the genus Helicobacter has rapidly expanded over the past decade. The genus now includes at least 24 formally named species as well as numerous other helicobacters awaiting formal naming. This review highlights the expanding role that other helicobacters, although not as well known as H pylori, play in gastrointestinal and systemic disease in humans.

Individual acid aspartic proteinases (Saps) 1-6 of Candida albicans are not essential for invasion and colonization of the gastrointestinal tract in mice

In order to investigate whether there is a role for individual secreted aspartic proteinases (Saps) of Candida albicans in gastrointestinal infection of mice we compared the differential expression of SAP1-6 genes and production of Sap1-6 proteins with invasion and persistence of SAP knockout strains in the gastrointestinal tract. Using an in vivo expression technology (IVET) we found a high percentage of expression of SAP4-6 genes which increased steadily in the course of infection. Expression of SAP1-3 genes was detected occasionally and in lower percentages than that of SAP4-6 genes. With reverse transcriptase-polymerase chain reaction (RT-PCR), mRNA for SAP 4 and SAP6 were detected in the stomach of all mice, whereas SAP2, SAP3 and SAP5 mRNA were detected not in all animals and SAP1 mRNA was not detectable. Also with immunoelectron microscopy we demonstrated production of Saps1-3 as well as Saps4-6 with antibodies cross-reacting with either Saps1-3 or Saps4-6. In contrast to the fact that gene expression and production of Saps were readily detectable, we were unable to demonstrate differences in the ability to invade the stomach, to disseminate to the brain as well as in the duration of faecal shedding and the number of fungi persisting in the faeces of mice infected with SAP knockout strains in comparison to control strains. We conclude that although Saps were produced, individual Saps were not indispensable factors for virulence during gastrointestinal infection of mice.

What to do about Helicobacter pylori? A decision analysis of its implication on public health

OBJECTIVES

Public health measures to eradicate Helicobacter pylori in the general population may prevent the occurrence of nonulcer dyspepsia (NUD), peptic ulcer (PUD) and gastric cancer, but may at the same time increase the prevalence of gastroesophageal reflux disease (GERD). A decision analysis is carried out to quantify the counteracting influences of H. pylori and resolve the controversy about a public policy to eliminate H. pylori from the general population.

METHODS

A compartment model is structured to analyze the jointly beneficial and adverse effects of H. pylori. Gastric acid, H. pylori infection, and other pathophysiological mechanisms influence the occurrence of reflux disease, peptic ulcer and dyspepsia, which all contribute to the occurrence of upper abdominal symptoms. Each influence is modeled as a separate compartment with various connections to other compartments. The simulation is carried out on an electronic spreadsheet.

RESULTS

A decision in favor or against eradication of all H. pylori depends primarily on the relative contribution of reflux disease vs. peptic ulcer and dyspepsia to upper abdominal symptoms in the general population. If reflux-related symptoms contribute twice more than peptic ulcer plus dyspepsia to the overall occurrence of abdominal symptoms, a strategy to eradicate H. pylori would actually lower rather than raise public health. Below this threshold such strategy may improve general well-being. In the individual patient infected with H. pylori, it remains beneficial to eradicate H. pylori, irrespective of the symptoms' nature.

CONCLUSIONS

Although it is advisable to treat H. pylori infection in the individual patient who comes to medical attention, a general policy directed towards complete elimination of H. pylori from the population would not be beneficial. A compartment model provides a simple yet powerful method to assess complex disease behavior.

High rate of false-negative results of the rectal swab culture method in detection of gastrointestinal colonization with vancomycin-resistant enterococci

The diagnostic accuracy of the rectal swab (RS) culture method in identifying gastrointestinal colonization with vancomycin-resistant enterococci (VRE) is not known. Serial quantitative stool cultures, skin cultures, and RS cultures were performed for patients with VRE infections to assess the false-negative rate of the RS and the prevalence of skin colonization, a prerequisite for cross-transmission, at varying VRE stool densities. A total of 35 stool samples were obtained from 13 patients. The sensitivity of the RS culture was 58%; it ranged from 100%, at VRE densities of > or =7.5 log10 colony forming units (cfu) per gram of stool, to 0%, at densities of < or =4.5 log10 cfu per gram of stool. Skin colonization was detected at these low VRE stool densities, but it was more common at higher VRE densities (P<.001). Antibiotic exposure was significantly associated with higher VRE stool densities (P<.001). The high false-negative rate of the RS may be contributing to the continued increase in the prevalence of VRE.

Invasive gastrointestinal zygomycosis in a liver transplant recipient: case report

BACKGROUND

Gastric zygomycosis is a rare but potentially lethal complication in transplant patients. Forty-two cases of gastric mucormycosis have been described in the literature, with a mortality of 98%.

METHODS

We report of a case of gastric mucormycosis in a 45-year-old male undergoing liver transplantation for alcohol-induced cirrhosis. The diagnosis was made 20 days after transplantation in a biopsy of a bleeding gastric ulcer identified during a reoperation for a common bile duct stricture.

RESULTS

After the surgical procedure and therapy with amphotericin B, the patient made a good recovery and is alive and well 2 years after transplantation.

CONCLUSIONS

Gastric mucormycosis should be suspected in those patients in whom gastrointestinal symptoms such a pain or bleeding are present. Because the diagnosis is dependent on histology, the importance of biopsy cannot be underestimated. Once diagnosed, a successful outcome depends on effective treatment with amphotericin.

[Evaluation of gene expression for cag A in strains of Helicobacter pylori colonizing gastric mucosa]

Recent studies indicate that infection with H. pylori strains expressing cytotoxic proteins such as cag A or vac A is an important risk factor for the development of chronic atrophic gastritis, gastric cancer, or MALT-type lymphoma. The aims of this study were: 1) to develop an RT-PCR assay for the analysis of cag A gene expression in H. pylori present in gastric mucosa specimens obtained during gastroendoscopy; 2) to examine with this method the correlation between the presence of cag A gene and its expression. The study was performed in 82 patients (40 females and 42 males). cag A DNA was detected in gastric mucosa in 42 patients, among them in 17 out of 35 with dyspepsia, in 14 out of 25 with peptic ulcer disease, in 2 out of 10 with gastric cancer and in 8 out of 11 with a family history of gastric cancer (Tab. 1). cag A gene expression could not be confirmed in only two cases positive for cag A DNA (both patients had a family history of gastric cancer, Fig. 1). The results of this study indicate that the RT-PCR assay is a useful tool for the molecular diagnostics of H. pylori infection. Further studies are needed to explain the role of cag A gene in the pathogenesis of peptic ulcer and gastric tumors.

[Intestinal microflora and concomitant gastrointestinal diseases in patients with chronic hepatitis B and C]

In chronic viral hepatitis B and C the development of intestinal dysbacteriosis and high occurrence of concomitant diseases of the gastrointestinal tract were observed. In cases of increased dysbacteriosis degree and in the presence of concomitant diseases the blood plasma of patients exhibited higher activity in reaction with the of amebocytes lysate obtained from crabs of the genus Limulus. A suggestion was made that the endotoxin of Gram negative intestinal microflora could probably play some role in the development of pathological processes in chronic viral hepatitis B and C.

Anthrax: ENT manifestations and current concepts

In light of recent events, anthrax has once again taken center stage in the world of science and the world in which we live. Because patients with anthrax may initially present to otolaryngology clinics, it is important for the otolaryngologist to know how to diagnose and treat this entity. This article will present current information on epidemiology, microbiology, pathogenesis/clinical manifestations, diagnosis, and treatment with a particular interest in the head and neck region.