Community-Onset Methicillin-Resistant Staphylococcus aureus Skin and Soft-Tissue Infections: Impact of Antimicrobial Therapy on Outcome

BACKGROUND

Conflicting data exist on the role of antimicrobial therapy for the treatment of uncomplicated community-onset methicillin-resistant Staphylococcus aureus (MRSA) skin and soft-tissue infections (SSTIs).

METHODS

We performed a retrospective cohort study of 492 adult patients with 531 independent episodes of community-onset MRSA SSTIs, which consisted of abscesses, furuncles/carbuncles, and cellulitis, at 2 tertiary care medical centers. The purpose of the study was to determine the impact of active antimicrobial therapy (i.e., the use of an agent to which the organism is susceptible) and other potential risk factors on the outcome for patients with uncomplicated community-onset MRSA SSTIs. Treatment failure was the primary outcome of interest and was defined as worsening signs of infection associated with microbiological and/or therapeutic indicators of an unsuccessful outcome. Bivariate analyses and logistic regression analyses were preformed to determine predictors of treatment failure.

RESULTS

An incision and drainage procedure was performed for the majority of patients. Treatment failure occurred in 45 (8%) of 531 episodes of community-onset MRSA SSTI. Therapy was successful for 296 (95%) of 312 patients who received an active antibiotic, compared with 190 (87%) of 219 of those who did not (P=.001 in bivariate analysis). Use of an inactive antimicrobial agent was an independent predictor of treatment failure on logistic regression analysis (adjusted odds ratio, 2.80; 95% confidence interval, 1.26-6.22; P=.01).

CONCLUSIONS

Our findings suggest that certain patients with SSTIs that are likely caused by MRSA would benefit from treatment with an antimicrobial agent with activity against this organism.

Variations in the postoperative management of free tissue transfers to the head and neck in the United Kingdom

Reliable assessment of the perfusion of free tissue transfers has always been a challenge for reconstructive microsurgeons. The complexities of flap microcirculation are often difficult to assess despite all the subjective and objective examination techniques available today, particularly when the free tissue transfer is buried, and not visible for monitoring. We investigated the post-operative management of free tissue transfers to the head and neck in the United Kingdom. Selected results from our survey show that the majority of units performed between two and five free tissue transfers to the head and neck region per month (n=60, mean=4.13, range<1-12). Clinical tests were used to monitor the flaps post-operatively in all units questioned. Hand held doppler was the most commonly used adjunctive technique, being routinely used for post-operative monitoring by twenty six units, and available for use in eighteen other units with the most common indications for use were, slow capillary refill and pale colour. Frequency and location of monitoring post-operatively was highly variable. Nurses were responsible for the routine monitoring of flaps in almost every unit. Thirty four units (57%) had a written protocol in place governing the monitoring of free tissue transfers post-operatively. We note the wide variation in practice on a national level, and make certain recommendations.

Clinical significance of isolated Staphylococcus aureus central venous catheter tip cultures

This retrospective cohort study examined the clinical significance of isolated Staphylococcus aureus central venous catheter (CVC) tip cultures (i.e., positive tip cultures without concomitant positive blood cultures). Subsequent S. aureus bacteraemia was found in nine (12%) of 77 patients at a median time of 4 days after CVC removal. A high co-morbidity score and no effective antibiotic treatment within 48 h of CVC removal were independent risk-factors for septic complications following multivariate analysis. A matched case-control study that compared the above cohort with patients with CVC tip cultures negative for S. aureus supported the significance of these findings.

Complications associated with the bacille Calmette-Guérin vaccination in Ireland

INTRODUCTION

BCG vaccination is currently recommended for all newborns in Ireland except where specifically contraindicated. This paper describes a marked increase in the number of referrals of patients with localised complications after vaccination to two Dublin paediatric hospitals. This increase coincided with the introduction of a new strain of BCG vaccine

METHODS

A population surveillance study was undertaken to determine the frequency and spectrum of complications associated with the new strain of BCG vaccine introduced in Ireland. Patients were identified though review of the infectious disease service case records and microbiology laboratory culture reports for the two year period from August 2002 to July 2004. Prospectively gathered data were supplemented by retrospective chart review. All infants who had inoculation site abscesses, suppurative adenopathy, or non-suppurative adenopathy with nodes > or =2 cm were included.

RESULTS

Fifty eight patients presented a median of 13 weeks post-inoculation: 32 with suppurative adenitis, 17 with inoculation site abscess, three with both inoculation site abscess and suppurative adenitis, and six with non-suppurative adenopathy. The overall complication rate was estimated at 1/931 vaccinees with 1/1543 developing suppurative adenitis. Twenty six infants required surgery.

DISCUSSION

This series illustrates the role of hospitals in sentinel surveillance and highlights the importance of having a well functioning and responsive system of adverse event reporting. These events raise a serious question as to the suitability of this vaccine strain for use in a national immunisation programme in a country where the prevalence of tuberculous disease is 10.4/100,000.

Pedicled flaps in the treatment of nonhealing perineal wounds

INTRODUCTION

A persistent sinus is an annoying complication following proctectomy. We examined the experience of a single colorectal surgeon in treating this condition using pedicled flaps.

METHODS

Case note review of all patients undergoing gracilis muscle transposition, Rectus abdominis muscle flap or omental flap for persistent perineal sinus.

RESULTS

Seventeen patients were identified: seven had gracilis muscle transposition, eight had omental transposition and two had a rectus abdominis flap. 13/17 patients who underwent a flap had a persistent sinus following proctectomy for Inflammatory bowel disease. Four patients who had a gracilis muscle transposition achieved healing. Seven out of eight patients had good results with omental transposition. One patient did well after a rectus abdominis flap.

CONCLUSIONS

A gracilis transposition is a relatively simple operation with minimal morbidity useful for superficial sinuses not requiring a muscle bulk. A rectus abdominis flap is a more complex specialized procedure with better results especially in dealing with larger cavities but it may compromise future stoma sites. Omentoplasty has excellent results, but is only available in some patients.

Jejunal Crohn's disease is associated with a higher postoperative recurrence rate than ileocaecal Crohn's disease

OBJECTIVE

Crohn's disease is a chronic inflammatory, panintestinal disease of uncertain aetiology. The recurrence rate of Crohn's disease, often taken as the time when further surgical procedure is undertaken, has been reported to be as high as 76% in 10 years. The site of the disease has not yet been associated with the recurrence rate of Crohn's disease. The aim of the study was to compare the outcome of patients who were surgically treated for jejunal Crohn's disease to those whose diseases was confined to the ileocaecal region.

METHOD

The information was tracked from our database of 724 surgically treated Crohn's disease patients between 1943 and 2002. Twenty-eight patients with jejunal Crohn's disease at their first operation (12 jejunum alone, 16 also involving other sites) were identified. For each of these patients, 3 patients with ileocaecal Crohn's, matched for age, sex, and smoking habits (n = 84) were identified as controls.

RESULTS

The median age in both groups was 21 years (range 16-52 years) with a median follow-up period of 19 years. The 3, 5 and 10 years re-operation rate for the groups with jejunal disease were 43%, 50% and 61% compared to 22%, 30% and 51% with ileocaecal disease, respectively.

CONCLUSIONS

The presence of jejunal Crohn's disease is associated with a higher rate of early disease recurrence compared to ileocaecal disease but long-term recurrences rate do not differ significantly.

Use of Long-Acting Tetracyclines for Methicillin-Resistant Staphylococcus aureus Infections: Case Series and Review of the Literature

BACKGROUND

Few data exist on the efficacy of the long-acting tetracyclines doxycycline and minocycline against methicillin-resistant Staphylococcus aureus (MRSA) infection.

METHODS

The medical records of 24 patients with serious tetracycline-susceptible MRSA infections who were treated with doxycycline or minocycline were reviewed. A review of the literature on the use of these antibiotics for treatment of both methicillin-susceptible and methicillin-resistant S. aureus infection was also performed.

RESULTS

Complicated skin and skin-structure infections were most common (67%). Clinical cure was achieved in 20 (83%) of 24 patients in our case series. Both drugs were well-tolerated. The review of the literature on a total of 85 patients with S. aureus infection revealed similar results.

CONCLUSIONS

Long-acting tetracyclines may be a reasonable treatment alternative for patients with certain types of MRSA infection.

Long strictureplasty is as safe and effective as short strictureplasty in small-bowel Crohn's disease

BACKGROUND

For the past 20 years it has been shown that intestinal strictureplasty is safe and effective in the management of short strictureplasty. Long strictureplasty (> 20 cm) may be an alternative to resection in some patients, especially in diffuse disease or after previous extensive resections. We reviewed the outcome of long strictureplasty for Crohn's Disease, to examine safety and recurrence rates, compared with conventional short strictureplasty.

METHODS

Sixty-two patients have undergone single strictureplasty for jejunoileal Crohn's disease since 1974. Median follow-up was 121 (range 7-253) months. Twenty-one operations involved a single long strictureplasty, and 41 operations had a single short strictureplasty.

RESULTS

No significant differences were identified between the groups. The postoperative complications in long strictureplasty included 2 abscesses only and after short strictureplasty there was one anastomotic leak and one postoperative abscess. The median hospital stay was 10 days after long strictureplasty and 9 days after short strictureplasty. Three-, 5- and 10-year disease-free rates for long and short strictureplasty, respectively, were 3-year 80.4% and 62.1%; 5-year 55.2% and 49.8% and 10-year 49.1% and 33.5% (NS).

CONCLUSIONS

These data indicate that long strictureplasty is safe and produces equivalent results to conventional (short) strictureplasty.

Non- epidermidis coagulase-negative staphylococcal bacteremia: clinical predictors of true bacteremia

In order to explore the clinical significance and risk factors for true bacteremia caused by coagulase-negative staphylococci (CNS) other than Staphylococcus epidermidis, a retrospective cohort study of 160 patients with at least one blood culture positive for non- epidermidis CNS was performed. True bacteremia was diagnosed in 32 (20%) of the patients. On multivariate analysis the following factors were associated with true bacteremia: (i) more than one positive blood culture, (ii) presence of a central venous catheter, and (iii) methicillin resistance. The results of this study indicate that non- epidermidis CNS can cause significant bloodstream infections.

Effects of the farnesyl transferase inhibitor R115777 on normal and leukemic hematopoiesis

Patients with acute myelogenous leukemia or myelodysplastic syndrome may respond to farnesyl transferase inhibitors (FTIs) with partial or complete response rates noted in about 30% of such patients. FTIs prevent the attachment of a lipid farnesyl moiety to dependent proteins prior to their insertion into the plasma membrane and thereby prevent activity of these prenylation-dependent proteins, but their mechanism of tumor suppression remains unknown. Many patients receiving FTIs do experience myelosuppression. In this work, the in vitro effects of the FTI, R115777 on normal and leukemic hematopoiesis have been examined as have its effects on apoptosis induction and cell cycle profile in both leukemic blasts and normal CD34+ cells. R115777 was inhibitory to normal CD34+ cell proliferation and to leukemic blast cells, but did not affect long-term culture initiating cell frequency nor NOD-SCID reconstituting capacity. No induction of apoptosis or cell cycle changes were noted in AML blasts. These data suggest that myelosuppression with R115777 occurs largely at the intermediate to late progenitor stage of hematopoiesis and that cyclic use might avoid long-term marrow suppression.

In vitro study of Listeria monocytogenes infection to murine primary and human transformed B cells

Immunity to Listeria monocytogenes is largely mediated by T lymphocytes. Recently, B lymphocytes or their secreted products are implicated to provide immunity against L. monocytogenes infection. To understand whether L. monocytogenes can infect and kill B cells as a possible strategy to initiate an infection, we examined the effects of L. monocytogenes on a human B lymphoma (Ramos RA-1) and mouse primary B cells in vitro. L. monocytogenes infection resulted in significantly (p<or=0.05) high cytotoxicity (58-79%) for Ramos and 39-68% cytotoxicity for mouse primary B cells. In contrast, non-pathogenic L. innocua caused only 1.2% cytotoxicity for Ramos and 19% for primary B cells. Bacterial cells were found frequently adhered to the B cell surfaces; however, active invasion was not a prerequisite for infection. L. monocytogenes caused loss of B cell surface molecules, pore formations, cell swelling, membrane damages and apoptosis. This study demonstrates that L. monocytogenes can infect and kill B cells as a possible strategy to initiate a successful infection.

National incidence of type 1 diabetes in childhood and adolescence

The Republic of Ireland is considered a region of low type 1 diabetes incidence compared with the British Isles and the rest of Europe. To establish a baseline national incidence of type 1 diabetes, in those under 15 years, with a measure of case ascertainment. Prospective active monthly reporting of incident cases by paediatricians was undertaken, with survey of adult physicians, endocrinologists and nurse specialists nationally. A secondary source of case ascertainment was employed. The crude incidence rate of type 1 diabetes was 16.6 per 100,000 per year and the directly standardised incidence rate was 16.3 per 100,000 per year. The Republic has a high incidence of type 1 diabetes. Services should be planned and resources allocated accordingly. A register should be established to monitor changes in this important disease. Further study is required to explore differing incidence in Northern and Southern Ireland.

Wegener's granulomatosis in India: clinical features, treatment and outcome of twenty-five patients

OBJECTIVE

To report our clinical experience on Wegener's granulomatosis (WG).

METHODS

A retrospective review of case records of all patients with WG in our Rheumatology Clinic during the period July 1988 to June 2000 was carried out and the details of demography, clinical and laboratory data, treatment and outcome were obtained and analysed.

RESULTS

Twenty-five patients (16 females and 9 males) were found eligible for inclusion in the study. The mean age and duration of symptoms at presentation were 33.5 years and 5.5 months, respectively. Two patients had limited WG. Twenty-two patients with generalized WG were treated with standard regimen comprising oral prednisolone (1 mg/kg/day) and oral cyclophosphamide (2 mg/kg/day). Cyclophosphamide was continued for at least one year after the patient attained remission. One patient was treated with intravenous cyclophosphamide regimen. The two patients with limited WG were treated with oral prednisolone and methotrexate (10-12.5 mg as a single dose per week). Remission was achieved in 24 patients after a median time of six months. The median follow-up of patients was five years (range 4 months-11 years). Five patients were lost to follow-up. Eight patients suffered a relapse. The mean time for relapse was 34 months after the initial remission. Seven out of eight patients remitted again after reinstitution of the initial induction regimen. One patient died of diffuse pulmonary haemorrhage despite early institution of therapy.

CONCLUSION

WG is being increasingly diagnosed in India now because of greater awareness and diagnostic aids. Although remissions are easy to achieve, relapses continue to pose a challenge to the treating physician.

Long-term outcome of undifferentiated spondylarthropathy

Undifferentiated spondylarthropathy is one of the common disease subsets in the group of so-called seronegative spondarthritides. It is not exactly known how often it differentiates into ankylosing spondylitis or other well-defined disease subsets over time. The present study was designed to find out the long-term outcome in this subset. Thirty-five patients diagnosed with undifferentiated spondylarthropathy between January 1987 and December 1988 were recruited. Twenty-two (63%) of them were available for detailed assessment 11 years after the original diagnosis. Their baseline characteristics did not differ from those of the original cohort of 35 patients and were as follows: male:female ratio 19:3, median age of onset 17 years (range 8-39), and median duration of disease 8 months (range 4-24). Clinical features were enthesitis (45%) and inflammatory pain in the back (100%), buttock (77%), hip (64%), shoulder (18%), knee (82%), ankle (77%), and hand and wrists (50%). There was no restriction in spinal movement. Family history was positive in two cases. Radiologically, the only finding was grade I sacroiliitis in 17 patients (77%). Human leukocyte antigen (HLA)-B27 was positive in all. Functionally, all were in class I. During follow-up, one patient developed psoriatic skin lesions after 9 years. Uveitis developed in four patients (18%). After a median follow-up of 11 years, 15 (68%) had ankylosing spondylitis, one developed psoriatic arthritis, four remained undifferentiated, and two had natural remission. Functionally, 19 patients (86%) were in class I and three (14%) were in class III. No patient had bamboo spine, but three underwent total hip replacement. Thus, a majority of patients (68%) with undifferentiated spondylarthropathy gradually developed ankylosing spondylitis of mild severity.