Outcomes of respiratory diphtheria in a tertiary referral infectious disease hospital

BACKGROUND

Diphtheria is a fatal disease and may cause serious complications if not recognized early and treated properly.

OBJECTIVES

To study the epidemiology, clinical features, complications, and outcomes in respiratory diphtheria.

MATERIALS AND METHODS

Diphtheria cases admitted in the infectious disease hospital, Beliaghata, Kolkata, India between January 2009 to January 2011 were evaluated in respect to demographic profile, immunization status, clinical features, complications, and outcomes.

RESULTS

200 diphtheria cases were studied. 150 (75%) patients had history of an adequate immunization, and 100 (50%) patients were from lower socio-economic groups. Common clinical features observed were throat pain in 148 (74%) cases and fever in 112 (56%) cases. Complications observed were myocarditis in 136 (68%) cases, neuropathy in 30 (15%) cases, and respiratory compromise in 14 (7%) cases. Death occurred in 5 (2.5%) patients.

CONCLUSIONS

diphtheria is still a public health problem in many developing countries. Strict public health measures like an increased immunization coverage, improvement of socio-economic status, easy availability of anti-diphtheritic serum (ADS), early recognition and effective treatment-all may reduce the incidence and mortality.

Causative pathogens of fever in neutropenic patients at King Chulalongkorn Memorial Hospital

BACKGROUND

Infections cause substantial morbidity and morbidity in neutropenic patients. In King Chulalongkorn Memorial Hospital, Gram-negative bacteria remained the most common causative pathogen of febrile neutropenia in all three studies conducted before 2002. However, Gram-positive bacteria have become more commonly isolated etiologic pathogens, and the incidence of fungal infection has been increasing since 2005.

OBJECTIVE

Determine the infectious etiology of fever in neutropenic patients at King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

MATERIAL AND METHOD

A retrospective chart review of all medical records of febrile neutropenic patients hospitalized at Department of Medicine between January 1 and December 31, 2006 in accompanying with microbiologic, radiologic, and serologic results was analyzed.

RESULTS

There were 125 patients (61 males and 64 females) and 172 episodes of febrile neutropenia with a mean age of 46.5 +/- 18.5 years (range: 15-81 years). The three most common primary diseases associated with neutropenia were acute myeloid leukemia, non-Hodgkin's lymphoma, and acute lymphoblastic leukemia (36.6%, 33.1%, and 10.5%). Infections could be documented microbiologically and clinically in 84 episodes (48.8%), and primary bacteremia or fungemia was the most common cause of infection (40.5%). Gram-negative bacteria were the most frequently isolated pathogens (63.9%), followed by Gram-positive bacteria (29.9%) and fungi (6.2%). Escherichia coli (46.8%) and coagulase-negative Staphylococcus (27.6%) were the most common isolates among Gram-negative and Gram-positive bacteria, respectively. Among 53 episodes (30.8%) of bloodstream infections, Gram-negative bacteria were the most commonly isolated pathogens (38 episodes, 71.7%), followed by Gram-positive bacteria (19 episodes, 35.8%) and Candida tropicalis (1 episode, 1.9%). Surprisingly, invasive mold infections were noted in eight episodes (5, 1, and 2 episodes of proven, probable, and possible infections, respectively). The overall mortality was 19.2%.

CONCLUSIONS

Although Gram-negative bacteria are the most common etiology of fever in neutropenic patients, the occurrence of infections caused by coagulase-negative Staphylococcus and molds has been increasing in comparison with the observations from previous studies in King Chulalongkorn Memorial Hospital. To authors knowledge, the present study is the first in Thailand to determine the occurrence of invasive fungal infections using the standard criteria recommended by EORTC/MSG.

[Febrile algo-eruptive illness in a French foreign legionnaire returning from Djibouti: gonococcal arthritis]

A French foreign legionnaire returning from Djibouti developed feverish polyarthritis with acral purpura. Diagnostic workup demonstrated gonococcemia contracted during unprotected fellatio. Based on this case report, diagnostic and therapeutic management is described.

Antipyretic, analgesic, anti-inflammatory and antioxidant activities of two major chromenes from Melicope lunu-ankenda

AIM OF THE STUDY

Melicope lunu-ankenda (Gaertn.) T.G. Hartley is used in Indian traditional medicine for fever, improving complexion and as a tonic. Previous studies have isolated fungicidal, antifeedant, anti-inflammatory and immunomodulatory compounds from Melicope lunu-ankenda. This study is aimed at the isolation and biological activity screening of potential molecules from the volatile oils and extracts of Melicope lunu-ankenda in the light of traditional applications.

MATERIALS AND METHODS

Volatile oil of Melicope lunu-ankenda leaves was isolated by hydrodistillation, characterized by GC-FID, GC-MS, LRI determination, Co-GC and database searches. Major chromene-type compounds in Melicope lunu-ankenda leaf oil, evodione and leptonol, were isolated by preparative TLC and characterized by UV-Vis, IR, 1H-, 13C-, 13C-DEPT NMR and EIMS. They were also isolated from the petroleum ether and acetone extracts of the leaves of Melicope lunu-ankenda by column chromatography in petroleum ether-ethyl acetate. Their contents in leaf oil, leaf and inflorescence extracts were estimated by HPTLC. Antipyretic (Baker's yeast-induced fever test), analgesic (acetic acid-induced writhing, tail immersion assays), anti-inflammatory (carrageenan-induced paw edema) and in vitro antioxidant (DPPH radical, superoxide radical scavenging) activities of evodione and leptonol were tested.

RESULTS AND CONCLUSIONS

Gas chromatographic analyses found 50.7% monoterpene hydrocarbons, 0.4% oxygenated monoterpenes, 3.2% sesquiterpene hydrocarbons, 0.7% oxygenated sesquiterpenes and 43.7% chromene-type compounds in Melicope lunu-ankenda leaf oil, with evodione (20.2%) and leptonol (22.5%) as its two major constituents. HPTLC estimations in the petroleum ether, acetone extracts (leaf, inflorescence) and leaf oil found evodione 1.0% (dr. wt., leaf), 1.1% (inflorescence), 0.04% (fr. wt. leaves, leaf oil), and leptonol 0.3% (leaf), 0.3% (inflorescence) and 0.04% (leaf oil). Leptonol (200 mg/kg) showed good antipyretic activity. DPPH radical scavenging assay found moderate activity for leptonol (68.7%, 500 microM), whereas evodione showed near-zero activity. A very similar trend was found in superoxide radical scavenging activity of leptonol (64.5%) and evodione (10.3%), both at 100 microg/ml. Evodione and leptonol showed moderate analgesic activities in acetic acid-induced writhing and tail immersion assays. Moderate anti-inflammatory activity was found for both evodione (59.4%) and leptonol (49.0%) at 100 mg/kg.

ETHNOPHARMACOLOGICAL RELEVANCE

Biological activities of evodione and leptonol isolated from Melicope lunu-ankenda justify its traditional uses as a remedy for fever, inflammation and as a tonic.

[Fever profile of febrile neutropenia in patients treated with cancer chemotherapy for hematological malignancies]

It is important to diagnose infectious events in cancer patients during chemotherapy. Since many of them have complications of febrile neutropenia (FN), determining its cause is critical for their treatment course. We analyzed all febrile events (>38.0 degrees C, single axillary temperature) in hospitalized cancer patients treated at Shizuoka Cancer Center over a period of 8 months. Based on the clinical presentation at the onset, we estimated the cause of fever and classified it as infection, tumor fever, immunologic reaction or unknown. Clinical presentations found at the onset of FN were categorized into 4 groups: (1) oral mucositis, and (2) respiratory, (3) gastrointestinal and (4) cutaneous findings. We detected 85 febrile episodes (median age 58, range 26 approximately 86; 37 males and 48 females). Neutropenia was observed (500/mL) in 52. 9% (45/85) of the patients and clinical symptoms were detected in 74.1% (63/85). In eleven of 18 infection-proven cases, we successfully predicted the infection focus at the onset of fever. Multivariate analysis revealed that initial high fever, antimicrobial prophylaxis, cutaneous findings and severe neutropenia were important influencing factors in predicting infectious disease during FN. Physical examination can support the diagnosis of the cause of fever in FN patients.

The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses

OBJECTIVES

To evaluate current processes by which young children presenting with a febrile illness but suspected of having serious bacterial infection are diagnosed and treated, and to develop and test a multivariable model to distinguish serious bacterial infections from self limiting non-bacterial illnesses. Design Two year prospective cohort study. Setting The emergency department of The Children's Hospital at Westmead, Westmead, Australia.

PARTICIPANTS

Children aged less than 5 years presenting with a febrile illness between 1 July 2004 and 30 June 2006.

INTERVENTION

A standardised clinical evaluation that included mandatory entry of 40 clinical features into the hospital's electronic record keeping system was performed by physicians. Serious bacterial infections were confirmed or excluded using standard radiological and microbiological tests and follow-up. Main outcome measures Diagnosis of one of three key types of serious bacterial infection (urinary tract infection, pneumonia, and bacteraemia), and the accuracy of both our clinical decision making model and clinician judgment in making these diagnoses.

RESULTS

We had follow-up data for 93% of the 15 781 instances of febrile illnesses recorded during the study period. The combined prevalence of any of the three infections of interest (urinary tract infection, pneumonia, or bacteraemia) was 7.2% (1120/15 781, 95% confidence interval (CI) 6.7% to 7.5%), with urinary tract infection the diagnosis in 543 (3.4%) cases of febrile illness (95% CI 3.2% to 3.7%), pneumonia in 533 (3.4%) cases (95% CI 3.1% to 3.7%), and bacteraemia in 64 (0.4%) cases (95% CI 0.3% to 0.5%). Almost all (>94%) of the children with serious bacterial infections had the appropriate test (urine culture, chest radiograph, or blood culture). Antibiotics were prescribed acutely in 66% (359/543) of children with urinary tract infection, 69% (366/533) with pneumonia, and 81% (52/64) with bacteraemia. However, 20% (2686/13 557) of children without bacterial infection were also prescribed antibiotics. On the basis of the data from the clinical evaluations and the confirmed diagnosis, a diagnostic model was developed using multinomial logistic regression methods. Physicians' diagnoses of bacterial infection had low sensitivity (10-50%) and high specificity (90-100%), whereas the clinical diagnostic model provided a broad range of values for sensitivity and specificity.

CONCLUSIONS

Emergency department physicians tend to underestimate the likelihood of serious bacterial infection in young children with fever, leading to undertreatment with antibiotics. A clinical diagnostic model could improve decision making by increasing sensitivity for detecting serious bacterial infection, thereby improving early treatment.

[Mycobacterial mediastinal adenopathy]

Tuberculosis is a frequent cause of prolonged fever. Mediastinal lymph node enlargement is an uncommon feature of intrathoracic tuberculosis in adults. The authors present the case of a 64 year old man who developed prolonged fever and was admitted to Clinical Hospital of Infectious Diseases and Pneumophtisiology Dr. Victor Babeş Timişoara during 06.04-15.04.2009. Diagnosis of mediastinal lymph node tuberculosis was established only after axillary thoracotomy and biopsy of tumoral mass, although the first results obtained after mediastinoscopy were negative. Dynamics of biological features, diagnostic pitfalls, differential diagnosis difficulties and peculiar aspects of evolution are presented. Mediastinal tuberculous adenopathy, without associated pulmonary involvement is a rare form of presentation among adults, generally evolving with sustained fever. Diagnosis of mediastinal tuberculosis is difficult due to non-specific clinical aspects and lack of characteristic radiographic features and so invasive diagnostic procedures gain importance (mediastinoscopy and biopsy).

Case studies of lower respiratory tract infections: community-acquired pneumonia

Community-acquired pneumonia (CAP) is a common and potentially serious illness with significant human and economic costs to society. The recent collaborative statement from the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) represents the most up-to-date evidence-based guidelines from North America, incorporating important advances in the management of patients with CAP. The cases presented in this review highlight many of the recent recommendations from the IDSA/ATS guidelines.

The diagnostic role of procalcitonin and other biomarkers in discriminating infectious from non-infectious fever

Fever is not only observed in the course of a bacterial or viral infection, but can be a symptom of, for instance, auto-immune, malignant or thromboembolic disease. Determining the etiology of fever in a fast and reliable way is of pivotal importance, as different causes of fever may ask for different therapies. Neither clinical signs and symptoms, nor traditional biomarkers, such as CRP, leukocytes and ESR have sufficient sensitivity and specificity to guide treatment decisions. In this review we focus on the value of traditional and newer biomarkers in non-infectious febrile diseases. Procalcitonin (PCT) seems to be the most helpful laboratory marker for the differentiation of causes of fever, particularly in autoimmune, autoinflammatory and malignant diseases.

To bronch or not to bronch? A recurring challenge in neutropenic patients with pulmonary infiltrates

BACKGROUND

Though it is generally accepted that both noninvasive and bronchoscopic procedures substantially increase the diagnostic yield ofpulmonaryinfiltrates, few studies address the therapeutic implications of invasive bronchoscopic procedures and their impact on survival.

METHODS

We prospectively followed all patients with neutropenic fever and pulmonary infiltrates who were either referred to the inpatient Pulmonary Consult Service of Yale New Haven Hospital or admitted to the Medical Intensive Care Unit between July 2006 andJuly 2008. One hundred forty-four patients with febrile neutropenia and associated pulmonary infiltrates were identified of whom 128 underwent flexible bronchoscopy.

RESULTS

A diagnosis was obtained in 91 (71%) of the 128 patients. The diagnostic yield was highest when sputum cultures, bronchoalveolar lavage andtransbronchialbiopsywere combined (70%; 95% CI, 57% to 80%). Survivalwas higher in patients who had an early diagnosis of the underlying cause of the pulmonary infiltrates. The results obtained with the different bronchoscopic techniques led to a change in antibiotic treatment in 70 cases (55%). In 35/128 patients (27%), bronchoscopic techniques led to a definite diagnosis otherwise not detected with nonbronchoscopic techniques. However, in 23% of the cases, where bronchoscopic techniques led to a definite diagnosis, the clinical information was not translated into appropriate changes of the antimicrobial management.

CONCLUSION

When noninvasive procedures are not likely to be diagnostic, bronchoscopic procedures should be performed soon after the occurrence of pulmonary infiltrates as early diagnosis improves survival.

[Watery diarrhea with fever: consider the possibility of pneumococcal meningitis]

The purpose of this report is to describe two rare cases of pneumococcal meningitis observed in Africa. Both cases were revealed by gastrointestinal symptoms characterized by abdominal pain and watery diarrhea. Due to the potential severity of bacterial meningitis, early diagnosis is required. Since diarrhea with fever is a common occurrence in Africa, differential diagnosis is necessary. Isolated diarrhea can be caused by meningeal syndrome and calls for testing to detect invasive pneumococcal infection.

[Paraparesis and fever in a Tunisian woman: cryptococcal spondylitis with spinal involvement]

Cryptococcus neoformans is a ubiquitous yeast that causes opportunistic infections mainly involving the central nervous system. Cryptococcoma is a rare entity characterized by a solid, tumor-like mass that is usually located in the cerebral hemispheres or cerebellum. Spinal involvement is rare with only 6 cases reported in literature. Bony involvement is also a rare occurrence that has been observed in only 5 to 10% of reported cases of infection by Cryptococcus neofomans. The purpose of this report is to describe a case of paraplegia due to cryptococcal spondylitis with spinal cord involvement in an HIV-seronegative patient with a history of systemic sarcoidosis. Diagnosis was achieved by histological examination of the surgical specimen.

[Diarrhoea and fever in chemotherapy patients due to listeriosis]

We present two patients with colorectal carcinoma who were admitted with fever and diarrhoea during treatment with chemotherapy. Blood cultures taken from both patients revealed an infection with Listeria monocytogenes. A contaminated ice cream was probably the source of infection in one patient. The other patient died of the listeriosis. Patients with diminished cellular immunity are at risk of invasive listeriosis. Listeriosis has a high mortality rate in this group of patients. Intravenous penicillin or ampicillin for 4 to 6 weeks is the first choice of antibiotic treatment. These antibiotics can be combined with an aminoglycoside or trimethoprim-sulfamethoxazole for a synergistic effect. To prevent invasive listeriosis we recommend strict dietary advice to all patients with diminished cellular immunity.

Fever/clinical signs and association with neutropenia in solid cancer patients--bacterial infection as the main cause

INTRODUCTION

Neutropenia remains one of the serious side effects of chemotherapeutics drugs making cancer patients face serious risk of infections. Fever and clinical signs are considered as important indicators. The objectives of this study were to assess fever and clinical signs with neutropenia onset and/ or severity in solid cancer cases, using culture tests to determine the type of bacteria predominating, whether gram positive or gram negative.

METHODS

This observational retrospective study was conducted on files of all solid cancer patients who admitted to a general hospital between 1 January 2003 and 31 December 2006. All data were categorical and analyzed for association with neutropenia.

RESULTS

117 neutropenic patients were studied, 83 (70.9%) of them suffering from fever ranging between 38.5-39 °C, with hypotension (53; 27.3%) and headache 51 (26.3%) as the most common clinical signs. Only 34 (29.1%) neutropenic patients underwent culture testing and only 14 (41.2%) showed positive growth, gram negative types predominating (9; 64.2%), mainly Escherichia coli (5; 35.7%), with gram positive only in 5 (35.7%). Significant associations were found for fever and clinical signs with neutropenia severity (P<0.05), but not neutropenia onset (P>0.05). Logistic regression results showed strong significant association between presence of fever (P=0.02, OR=1.3) (95% confidence interval (CI)) hypotension and headache (P=0.001, OR=1.148) (95% CI) with neutropenia severity.

CONCLUSION

Fever and clinical signs specifically headache and hypotension are symptoms associated with severe neutropenia in solid cancer patients. Both may primarily result from bacterial infection, particularly gram negative forms.

[Chronic abdominal pain and fever in an Ivoirian woman: Mycobacterium avium-intracellulare duodenitis in an AIDS patient in Abidjan, Cote d'Ivoire]

Duodenal infection by Mycobacterium avium-intracellulare is a common opportunistic disease in HIV-infected patients. Individuals with CD4 counts <50 cells/mm3 are at highest risk. The main symptoms are diarrhea, abdominal pain, weight loss, and fever. Endoscopic examination shows various abnormalities including disseminated nodules that may be yellowish, whitish, or pinkish in color. Other mucosal lesions may be found such as erosion, erythema, or friable edematous aspect. Since these findings are non-specific, it is important to obtain biopsy specimens for histological and microbiological examination. The most common histologic features are atrophic mucosa resembling Whipple's disease with strongly positive PAS staining. The presence of BARR in macrophages is typical of MAI. Diagnosis is based on identification of the bacteria using either conventional culture techniques or polymerase chain reaction (PCR). Differential diagnosis includes other gastrointestinal infections associated with AIDS, i.e., microsporidiosis, cryptosporidiosis, giardiosis, anguillulosis, CMV, and isoporosis. The course of the disease is usually unfavorable even with antibiotic treatment. The purpose of this report is to describe a case of duodenitis due to atypical mycobacterial infection in a 30-year-old woman who was seropositive for human immunodeficiency virus. She was hospitalized due to fever with deterioration of her general condition (more than 10% of body weight loss) and chronic abdominal pain with inflammation. Diagnosis of MAI was confirmed by biopsy and Ziehl-Neelsen coloration. The patient was treated with rifampicine, isoniazide, ethambutol, and pyrazinamide in association with stavudine, lamuvidine and efavirenz. Despite improvement of general condition, fever persisted and the patient died after 40 days of treatment.

Prophylactic antibiotics and evaluation scheme following febrile urinary tract infection in children: a nationwide Israeli survey

BACKGROUND

Although febrile urinary tract infections are very common in young children, the need for antimicrobial prophylaxis and evaluation following a first event is controversial.

OBJECTIVES

To assess the approach of leading pediatric specialists throughout israel to antimicrobial prophylaxis.

METHODS

A questionnaire regarding the approach to antibiotic prophylaxis and diagnostic evaluation following a first event of febrile UTI, according to age and underlying renal abnormality, was sent to all 58 directors of departments of pediatrics, units of pediatric infectious diseases and pediatric nephrology in Israel.

RESULTS

Fifty-six directors (96%) responded. Most prescribed prophylactic antibiotics after UTI. Heads of infectious disease departments prescribed less prophylaxis following UTI at the age of 18 months than heads of pediatrics or heads of pediatric nephrology units (34% vs. 72-75%, P = 0.018), but more often in cases of severe vesico-ureteral reflux without UTI. Cephalosporins were used prophylactically more often by directors of pediatrics compared to heads of pediatric nephrology units (71% vs. 38%, P = 0.048); the latter used non-beta-lactam prophylaxis (61% vs. 23%, P = 0.013) more often. Most pediatricians used renal sonography for evaluation; renal scan was used more commonly by pediatric nephrologists.

CONCLUSIONS

The administration of prophylactic antibiotics after UTI is still common practice among pediatric opinion leaders, although the specific approach differs by subspecialty. According to the latest evidence-based data, educational efforts are needed to formulate and implement judicious guidelines.

C-reactive protein as a marker of serious bacterial infections in hospitalized febrile infants

OBJECTIVE

To determine the potential predictive power of C-reactive protein (CRP) as a marker of serious bacterial infection (SBI) in hospitalized febrile infants aged < or =3 months.

PATIENTS AND METHODS

Data on blood CRP levels were collected prospectively on admission for all infants aged < or =3 months who were hospitalized for fever from 2005 to 2008. The patients were divided into two groups by the presence or absence of findings of SBI.

RESULTS

A total of 892 infants met the inclusion criteria, of whom 102 had a SBI. Mean CRP level was significantly higher in the infants who had a bacterial infection than in those who did not (5.3 +/- 6.3 mg/dL vs. 1.3 +/- 2.2 mg/dL, p < 0.001). The area under the ROC curve (AUC) was 0.74 (95% CI: 0.67-0.80) for CRP compared to 0.70 (95% CI: 0.64-0.76) for white blood cell (WBC) count. When analyses were limited to predicting bacteremia or meningitis only, the AUCs for CRP and WBC were 0.81 (95% CI: 0.66-0.96) and 0.63 (95% CI: 0.42-0.83), respectively.

CONCLUSION

C-reactive protein is a valuable laboratory test in the assessment of febrile infants aged < or =3 months old and may serve as a better diagnostic marker of SBI than total WBC count.

[Nodular liver lesions with fever in a Moroccan man: hepatic brucelloma]

Hepatic brucelloma is an exceptional localization in brucellosis. The purpose of this report is to describe an uncommon case involving a 42-year-old man hospitalized for febrile hepatic cytolysis. Diagnosis was established based on positive rose bengal test results, positive blood culture, hypoechogenic masses on ultrasound, and hypodense enhancing masses on CT scan. Hepatic brucelloma is a focal suppurative lesion occurring after undetected acute brucellosis or undertreated brucellosis. Diagnosis is based on the association of imaging showing characteristic features (hepatic calcifications) and on positive blood culture and serology. First-line treatment should consist of doxycyclin and rifampicin for 2 to 12 months. If medical treatment fails, surgical drainage should be performed.

Significance of C-reactive protein during febrile neutropenia in pediatric malignancies

Fifty episodes of febrile neutropenia (FN) in 33 children with malignancies were studied to evaluate the usefulness of C-reactive protein (CRP) levels as an indicator of infection, and the efficacy of antibiotic therapy. Nineteen FN episodes occurred in children with documented infection whereas, 9 and 22 episodes occurred with probable infection and fever of unknown origin, respectively. CRP positivity during episodes of documented and probable infection was significantly higher than with febrile episodes of unknown origin. Blood culture was positive in 15 episodes; of these, CRP was positive in 11. CRP declined to normal on 7th day of antibiotic therapy. CRP is a useful indicator of infection in neutropenic children and also in determining the efficacy of antibiotic therapy.

[Treatment of urinary tract infections in febrile infants: experience of outpatient intravenous antibiotic treatment]

OBJECTIVE

To describe the feasibility, effectiveness and safety of intravenous (iv) outpatient treatment in 2 to 24 month-old children with febrile urinary tract infection (UTI).

METHOD

Children presenting to the ER, between April 2003-2005, with fever and no identifiable focus who had a diagnosis of UTI were randomized to receive iv antibiotic in the hospital or in an outpatient facility. Children were started on amikacin or ceftriaxona according to physician criteria followed by antimicrobial adjustment based on urine culture result and a later switch to an oral antimicrobial. Urine cultures were performed during and after completing the antimicrobial course. Adherence and effectiveness of antimicrobial treatment and treatment-associated complications were analyzed.

RESULTS

The study included 112 patients, 58 inpatient children and 54 outpatient children, with an average age of 7.7 months. Duration of iv treatment did not differ among groups (2.8 days (SD 1.2) 2.7 +0.91 days in inpatients vs 2.9 + 1.9 days in outpatients (p = 0.22). In 100% of outpatient children and 100% of inpatient children (overall 101/101) urine cultures were negative on day 5. None of the children had a treatment-associated complication. Cost analysis yielded 73% of saving money (overall cost for inpatient treatment US 9,815 vs outpatient treatment US 2,650).

CONCLUSIONS

Outpatient iv treatment in patients between 2 and 24 months with UTI and fever was effective, safe and of lower cost.

Venous catheter-associated bacteremia caused by rapidly growing mycobacteria at a medical center in central Taiwan

BACKGROUND AND PURPOSE

Infections due to rapidly growing mycobacteria (RGM) are increasing worldwide, especially in immunocompromised hosts, but data on the clinical features of patients with RGM bacteremia are limited in Taiwan. This study was performed to determine the features associated with RGM.

METHODS

The medical records of 12 patients with RGM bacteremia admitted to the Changhua Christian Hospital, Changhua, Taiwan, from April 2001 to March 2003 were retrospectively studied. Clinical data were reviewed and antimicrobial susceptibility testing of blood isolates by the agar disk elution method was performed.

RESULTS

RGM bacteremia was caused by Mycobacterium fortuitum in 5 patients, Mycobacterium smegmatis in 3, Mycobacterium flavescens in 2, and Mycobacterium abscessus in 2. There were 5 men and 7 women (age range, 4-75 years). All patients had underlying diseases and all of the infections were associated with an indwelling vascular catheter. The time to onset of bacteremia ranged from 1 to 24 months. Fever (n = 11) was the most common presenting symptom. Susceptibility testing revealed a different antibiogram for each species of RGM. The rate of relapsing bacteremia was significantly higher in patients with delayed catheter removal and for whom the catheter was not removed (6/8; 75%) than in patients with timely catheter removal (0/4; 0%) [p = 0.03].

CONCLUSIONS

RGM bacteremia is rare but should be considered in immunocompromised patients with an indwelling venous catheter and undifferentiated fever. Identifying RGM at the species level and performing susceptibility testing are useful for guiding management. The catheter should be removed as soon as possible.

Sennetsu neorickettsiosis: a probable fish-borne cause of fever rediscovered in Laos

Neorickettsia sennetsu has been described from Japan and Malaysia, causing a largely forgotten infectious mononucleosis-like disease. Because it is believed to be contracted from eating raw fish, frequently consumed in the Lao PDR, we looked for evidence of N. sennetsu among Lao patients and fish. A buffy coat from 1 of 91 patients with undifferentiated fever was positive by 16S rRNA amplification and sequencing and real-time polymerase chain reactions (PCR) targeting two N. sennetsu genes. Lao blood donors and patients with fever, hepatitis, or jaundice (N = 1,132) had a high prevalence (17%) of immunofluorescence assay IgG anti-N. sennetsu antibodies compared with 4% and 0% from febrile patients (N = 848) in Thailand and Malaysia, respectively. We found N. sennetsu DNA by PCR, for the first time, in a fish (Anabas testudineus). These data suggest that sennetsu may be an under-recognized cause of fever and are consistent with the hypothesis that it may be contracted from eating raw fish.

A multi-centre prospective study of febrile neutropenia in Norway: Microbiological findings and antimicrobial susceptibility

The urgent need to treat presumptive bacterial or fungal infections in neutropenic patients has meant that initial therapy is empiric and based on the pathogens most likely to be responsible, and drug resistance. The traditional empirical treatment in Norway has been penicillin G and an aminoglycoside, and this combination has been criticized over recent y. We wished to analyse the microbiological spectrum and susceptibility patterns of pathogens causing bacteraemia in febrile neutropenic patients. This was a prospective multicentre study. During the study period of 2 y, a total of 282 episodes of fever involving 243 neutropenic patients was observed. In 34% of episodes bacteraemia was documented. Overall, 40% of the episodes were caused by Gram-positive organisms, 41% by Gram-negative organisms and 19% were polymicrobial. The most frequently isolated bacteria were Escherichia coli (25.6%), a- and non-haemolytic streptococci (15.6%), coagulase-negative staphylococci (12.4%) and Klebsiella spp. (7.4%). None of the Gram-negative isolates was resistant to gentamicin, meropenem, ceftazidime or ciprofloxacin. Only 5 coagulase-negative staphylococci isolates were resistant to both penicillin G and aminoglycoside. The overall mortality rate was 7%, and 1.2% due to confirmed bacteraemic infection.

Early prediction of infection after craniotomy for brain tumours

Reliably predicting infection soon after craniotomies would prevent infection and reduce treatment costs and hospitalization expenses. Therefore we analysed potential risk factors and blood count data after craniotomies for brain tumours in order to predict infection as soon as possible after surgery. We analysed 139 patients who underwent craniotomies for brain tumours from January 1997 to December 2001, and divided them into four categories (Types A to D) according to the following: increase in their white blood counts (WBCs) from Day 0 to Day 1, maximum WBC between Day 0 and Day 2, and maximum c-reactive protein (CRP) between Day 0 and Day 4 after surgery. We evaluated potential risk factors and the blood count data for infections via logistic regression analysis. Type D patients had a significantly higher rate of infection (p = 0.0123) than the other Types, while Type B patients had the lowest rate among the four groups (p = 0.0006). When Type A patients suffered CSF leakages, they had a significantly higher possibility of meningitis (p < 0.0001) or scalp infection (p = 0.012). In those Type A or D patients who were male, more than 70 years old, and suffered from metastases from primary lung cancer lesions, the possibility of pneumonia was significantly higher (p = 0.0178). In conclusion, we are able to predict infection within four days after craniotomies for brain tumours according to standard blood count data and certain risk factors. This possibility allows for improved care and better clinical outcomes in patients that undergo craniotomies for brain tumours.

Infective endocarditis--a forgotten cause for heart insufficiency in elderly. Case report

Right heart infective endocarditis in an elderly patient with no previous known risk factors is a very rare situation (even if subacute infective endocarditis has the same chance of occurrence at either a young person, or an elderly patient). We present the case of a 75-years old patient, with no previous cardiac history, addressed to our clinic with nonspecific septic symptoms associated with an edematous syndrome. The patient was treated for right heart valve infective endocarditis; a particularity may be the fact not all Duke criteria were respected. Iatrogeny was involved, our patient having administered a 7-day antibiotic treatment before hospital addressing. The therapeutic probe was positive: excellent evolution under treatment. Few cases of infective endocarditis of the tricuspid valve were reported worldwide, in which the source of infection was unknown in about 80% of cases. In two pediatric cases reported, tricuspid endocarditis was caused by Staphylococcus aureus septicemia following upper respiratory infection. This may also occur in adult cases. Further investigations should be carried out in the future to elucidate the source of infection. Isolated right-sided endocarditis should be included in the differential diagnosis of patients with febrile syndrome, respiratory symptoms and predisposing disease, even when they do not have a pacemaker and are not intravenous-drug users (IVDU).

Serious bacterial infections in febrile infants in the post-pneumococcal conjugate vaccine era

OBJECTIVES

The objective was to identify the epidemiology of serious bacterial infections (SBI) and the current utility of obtaining routine complete blood counts (CBC) and blood cultures to stratify infants at risk of SBI, in the study population of febrile infants in the post-heptavalent pneumococcal conjugate vaccine (PCV7) era.

METHODS

A cohort study with nested case-controls was undertaken at a tertiary care military hospital emergency department (ED) from December 2002 through December 2003. Irrespective of clinical findings at the initial encounter, patients were included if they were under 3 months of age and had a home or ED temperature of >or=100.4 degrees F or if they were between 3 and 24 months of age with a temperature of >or=102.3 degrees F. Data abstracted included age, temperature, peripheral white blood cell (WBC) count, and discharge diagnosis. Culture (blood, urine, and cerebrospinal fluid [CSF]) and chest radiograph (CXR) results were obtained through review of the electronic hospital archives. SBI was defined as pneumonia, urinary tract infection (UTI), meningitis, or bacteremia.

RESULTS

A total of 985 children aged 0 to 24 months were enrolled. Fifty-five percent were male, the median age was 12 months (interquartile range = 8-17 months), and 79% had received at least one PCV7. A total of 132 cases of SBI were identified in 129 infants (13.1%): 82 pneumonias, 45 UTI, five bacteremias, and no cases of bacterial meningitis. The frequency of bacteremia was 0.7%. No statistical difference was detected in the WBC count between the SBI and non-SBI groups (13.8 +/- 5.8 and 11.7 +/- 5.6, respectively; p = 0.055). No readily available WBC cutoff on the receiver operating characteristic (ROC) curve proved to be an accurate predictor of SBI. No statistical difference was detected in mean temperature between the SBI and non-SBI groups (103.3 +/- 1.2 and 103.2 +/- 1.2 degrees F, respectively; p = 0.26), nor was there a difference noted when groups were broken down by age or height of fever.

CONCLUSIONS

The WBC count and height of fever were not found to be accurate predictors of SBI in infants age 3 to 24 months. UTI and pneumonias made up the vast majority of SBI in this population of infants. The overall bacteremia frequency was well below 1%. This calls into question the continued utility of obtaining routine complete cell counts and blood cultures in the febrile infant in the post-PCV7 era.

[Hepatic tuberculosis presenting as prolonged fever]

In our country prolonged fever is frequently caused by tuberculosis infection, that is recrudescent. Localized hepatic tuberculosis is a rare clinical form of this specific infection. The authors present the case of a 26 year old man who developed prolonged fever, highly elevated liver enzymes and meningitis syndrome and was admitted to Clinical Hospital of Infectious Diseases and Pneumophtisiology Dr. V. Babeş Timişoara during 24.03 - 16.05.2008. Diagnosis of hepatobiliary tuberculosis, acute bacillary meningitis and miliary tuberculosis were established by clinical, laboratory criteria and sustained by imaging techniques. Dynamics of biological features, diagnostic pitfalls, differential diagnosis difficulties, therapeutic schedules and peculiar aspects of evolution are presented. Liver involvement can be the only manifest form of miliary tuberculosis and when it is associated with prolonged fever obligates to begin quadruple specific therapy, especially in communities where tuberculosis is prevalent. Bacteriological findings are belated and antituberculous therapy can not be started early. Quadruple association of antituberculous drugs with corticotherapy and liver protective medication showed utility in favorable resolving of this case.

Risk index score for bacteremia in febrile neutropenic episodes in children with malignancies

PURPOSE

To prospectively determine risk factors for bacteremia in febrile neutropenic children with malignancies.

PATIENTS AND METHODS

We studied 199 episodes of febrile neutropenia in 80 children with malignancies, treated by conventional chemotherapy for a 4-year period (2000 - 2004). A standardized computer database with a set of variables for each febrile neutropenic episode was used. C-reactive protein (CRP) was measured at the first febrile episode and on the 3rd and 5th day from the beginning of antibiotic therapy by immunoturbidimetric method. Blood cultures were taken at the onset of fever and before initiation of antibiotic therapy.

RESULTS

Multivariate logistic regression analysis determined 5 variables as independent risk factors for bacteremia: the underlying malignant disease (leukemia, non - Hodgkin's lymphoma / NHL, stage IV), chills, perianal cellulitis, presence of central venous catheter and CRP rise >or=34.5 mg/L between the onset of fever and the 3rd day of empiric antibiotic therapy. Thus we identified a low-risk group for bacteremia of 19.1%.

CONCLUSION

Serial measurement of CRP allows for definite risk stratification of febrile neutropenic episodes on the 3rd day from the onset of fever. The low-risk group could be eligible for sequential empiric antibiotic therapy.

Urinary tract infection in febrile children in Maiduguri north eastern Nigeria

One hundred and forty five children aged 1 month to sixty months who had fever at presentation to the paediatric department of University of Maiduguri Teaching Hospital were investigated for urinary tract infection in this prospective study from November 2004 to October 2005. Prevalence of urinary tract infection was found to be 13.7 per cent. While the female sex and malnutrition were found to be significantly associated with urinary tract infection, height of temperature and symptoms referable to urinary system were not. Ninety per cent of the isolates were Gram negative; mainly coliform Spp, the remaining 10 per cent were due to staphylococcus aureus. Gentamicin was still found to be effective against most of the urinary pathogens. However, clavulinic acid potentiated amoxicillin, ampicillin, nalidixic acid and cotrimoxazole were found to be poorly effective. We therefore conclude that all ill children especially younger ones presenting with fever be screened for urinary tract infection. A regular surveillance of urinary tract infection pathogens and their antibiotic sensitivity pattern is recommended.

Teicoplanin in combination: role in the management of the febrile neutropenic patient

The spectrum of microorganisms responsible for infection in neutropenic patients has changed in the last decade, with Gram-positive organisms now predominant. New antibiotic strategies have been required and have evolved to cope with this change. In particular, the optimal timing of glycopeptide antibiotic use has been addressed. Both teicoplanin and vancomycin are highly effective agents for susceptible Gram-positive organisms. Teicoplanin has advantages in terms of ease of administration and lower toxicity, while vancomycin has proved durable over many years' use. There are now firm indications for the use of glycopeptide antibiotics in febrile neutropenic patients, including clinically defined central venous catheter infection and microbiologically documented infection with susceptible organisms. The empirical use of the glycopeptide antibiotics in combination with other agents as first-line treatment, however, is less certain. The utility of this approach remains controversial and ultimately depends on the extent to which local practice favours the emergence of Gram-positive infections in neutropenic patients.

Teicoplanin versus vancomycin in the empirical treatment of febrile neutropenic patients

Gram-positive infections have become prevalent among neutropenic patients with cancer. A prospective, randomized, double-blind trial of teicoplanin, 6 mg/kg every 12 h for three doses then every 24 h, versus vancomycin hydrochloride, 15 mg/kg every 12 h, in the empirical treatment of febrile neutropenic patients was undertaken among 50 consecutive patients with haematological malignancy. The patients also received piperacillin sodium, 3 g every 4 h, and tobramycin sulphate, 1.5-2 mg/kg every 8 h. Both groups (25 teicoplanin and 25 vancomycin) were comparable in age, sex, renal function, underlying disease and concurrent therapy. Among 22 patients (44%) with culture-proven infection, Gram-positive organisms were isolated in 15 (9 with bacteraemia) and Gram-negative in 11 (4 with bacteraemia). Mixed or polymicrobial infection occurred in 8 patients. Serum 1-h peak and trough levels at steady state were 41 +/- 15 and 12 +/- 3 mg/l for teicoplanin (at 14 +/- 4 days), and 40 +/- 10 and 8 +/- 5 mg/l for vancomycin (at 0.9 +/- 0.6 days). Mean elimination half-life and apparent volume of distribution at steady state were 80.5 +/- 21.5 h and 1.4 +/- 0.8 l/kg for teicoplanin, and 5.6 +/- 1.8 h and 0.6 +/- 0.2 l/kg for vancomycin. Empirical antimicrobial therapy was successful in 23 teicoplanin and 21 vancomycin patients, respectively (p = 0.67; two-tailed Fisher's exact test). Nephrotoxicity (serum creatinine > 110 mmol/l), however, was more common among vancomycin patients (10 versus 2; p = 0.02), while termination of treatment due to adverse effects was also more common among vancomycin patients (10 versus 2; p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Extended septic thrombophlebitis in a patient with duplicated inferior vena cava: case report and review of literature

Duplication is one of the congenital abnormalities of the inferior vena cava (IVC) and is reported to be associated with deep venous thrombosis (DVT). We report a case who was admitted for carbamazepine-induced toxic epidermal necrolysis. The patient had persistent fever caused by septic thrombophlebitis extending from the left femoral vein to the duplicated left IVC. The fever and thrombosis resolved under combined treatment with antibiotics and anticoagulants, without further complication of symptomatic pulmonary embolism. This is the first case in patient with IVC duplication complicated by DVT induced by septic thrombophlebitis, which was not seen in the nine cases of IVC duplication reported previously.

[Etiology of febrile neutropenia episodes among cancer patients from Hospital Clinico Universidad Catolica, Santiago-Chile]

INTRODUCTION

The surveillance of febrile neutropenia (FN) episodes in every center allows adapt the antibiotic therapy guidelines to local epidemiology.

AIM

To characterize clinical features and compare the FN etiology between hematological cancer (HC) and solid organ cancer (SOC) in our center.

PATIENTS AND METHODS

Surveillance study in adult patients with FN admitted to Hospital Clinico Universidad Católica, in Santiago, Chile, from January 2004 to August 2007.

RESULTS

154 FN episodes corresponding to 87 patients were included. Mean age: 47 +/- 6 years-old; 71% had HC and 29% SOC. A clinical and/or microbiologically documented infection was recognized in 76%. Gastrointestinal 31.5%, upper respiratory 30.3% and lower respiratory 16.9% were the more frequent clinical focus. In 30.5% blood culture resulted positive: gram negative rods 51%, gram positive cocci 41% and yeasts 8%; being Escherichia coli 22%, S. coagulase negative (SCoN) 20% and Klebsiella pneumoniae 12% most frequent bacteria; 22.2% Enterobacteriaceae were ESBL producers and 55.6% 5CoN were methicillin resistant. In 18.3% of FN episodes the etiology was not established. Highest mortality was observed in episodes with microbiologically documented infection (14.5% vs 1.3%, p < 0.005). A clinical observed focus and positive blood cultures were more frequently obtamed among HC than SOC associated episodes: 37.3% vs 13.6%; (p < 0.01) and 67.2% vs 50%; (p = 0.045), respectively.

CONCLUSIONS

The etiological profile of FN in our center and the necessity to continue the surveillance was described. Future studies are needed regarding risk factors of invasive infection that have worst prognosis.

Community-acquired bacterial meningitis in elderly patients: experience over 30 years

Clinical characteristics, etiologies, evolution, and prognostic factors of community-acquired bacterial meningitis in elderly patients are not well known. To improve this knowledge, all episodes of community-acquired bacterial meningitis were prospectively recorded and cases occurring in patients >or=65 years old were selected. During the period 1977-2006, 675 episodes in adults (aged >or=18 yr) were recorded, with 185 (27%) in patients aged >or=65 years old; 76 were male and 109 were female, with a mean age of 73 +/- 6 years (range, 65-93 yr). Causative microorganisms were Streptococcus pneumoniae 74, Neisseria meningitidis 49, Listeria monocytogenes 17, other streptococcal 9, Escherichia coli 6, Haemophilus influenzae 4, Klebsiella pneumoniae and Staphylococcus aureus 2 each, Capnocytophaga canimorsus and Enterococcus faecalis 1 each, and unknown in 20. On admission 91% had had fever, 32% were in a coma (Glasgow Coma Scale <or=8), 9% presented with seizures, and 8% with shock. Thirty patients (16%) presented with seizures during therapy. Mortality was 58/185 (31%). Compared with patients aged 18-65 years, there were significant differences among older patients (aged >or=65 yr), who showed a higher frequency of diabetes and malignancy as underlying disease; pneumonia, otitis, and pericranial fistula as predisposing factors; and S. pneumoniae and L. monocytogenes as etiology. There were also differences in clinical presentation, complications, sequelae, and mortality. Factors independently related with mortality were age, pneumonia as a predisposing factor, coma on admission, and heart failure and seizures after therapy. Dexamethasone therapy was a protective factor. In conclusion, bacterial meningitis in elderly patients is associated with greater diagnostic difficulties and neurologic severity and more complications, as well as with increased mortality. Antiseizure prophylaxis might be useful in these patients.

Prevalence of occult bacteremia in children aged 3 to 36 months presenting to the emergency department with fever in the postpneumococcal conjugate vaccine era

OBJECTIVES

The goal of this study was to identify the prevalence of occult bacteremia (OB) in well-appearing, previously healthy children aged 3 to 36 months who present to the emergency department (ED) with fever without source in the post-pneumococcal conjugate vaccine (PCV) era.

METHODS

This was a retrospective cohort study of children presenting to an urban pediatric ED between July 1, 2004, and June 30, 2007. Children were included if they were aged 3 to 36 months, febrile, and previously healthy; had no source of infection on examination; had a blood culture drawn; and were discharged from the ED. Outcome measures were rates of OB and contaminant rates.

RESULTS

A total of 8,408 children met all inclusion criteria. There were 21 true-positives, yielding an OB rate of 0.25% (95% confidence interval [CI] = 0.16% to 0.37%). There were 159 contaminant cultures yielding a contaminant rate of 1.89% (95% CI = 1.61% to 2.19%), or a ratio of 7.6 contaminants for each true-positive. There were 14 included patients who grew Streptococcus pneumoniae from the blood, for a rate of 0.17% (95% CI = 0.09% to 0.27%).

CONCLUSIONS

Given the current rate of OB in the post-PCV era, it may no longer be cost-effective to send blood cultures on well-appearing, previously healthy children aged 3 to 36 months who have fever without source.