Microbiological studies of the round goby (Neogobius melanostomus) from the Puck Bay, southern Baltic Sea

In summer 2017 numerous dead round gobies ( Neogobius melanostomus) and individuals covered with white coating were observed in the Puck Bay. The aim of our research was to determine the microbiological composition of the round goby from the Puck Bay, focusing on the presence of pathogens. Bacteria were identified by biochemical methods and, by sequencing of 16S rRNA. The dominant bacterial species were Shewanella baltica, Pseudomonas spp. and Aeromonas spp. - opportunistic pathogens, commonly present in many fish species, which may become harmful for the organism in unfavorable conditions. It was the first trial to determine the composition of the bacterial flora of N. melanostomus from that area.

In vitro activity of fosfomycin alone and in combination against Staphylococcus aureus with reduced susceptibility or resistance to methicillin, vancomycin, daptomycin or linezolid

OBJECTIVES

To evaluate the activity of fosfomycin against a group of MRSA strains, including isolates with reduced susceptibility or resistance to vancomycin, daptomycin, linezolid and ceftaroline and to determine the effect of combining various combinations of antimicrobial agents used in the therapy of serious Gram-positive infections.

METHODS

Broth microdilution testing was used to determine the MICs of fosfomycin, vancomycin, daptomycin, linezolid, ceftaroline and cefazolin. Isolates were selected for further evaluations to determine in vitro synergy between fosfomycin and select antimicrobial agents using chequerboard broth microdilution testing. Fosfomycin was tested in combination with vancomycin, linezolid, daptomycin, ceftaroline and cefazolin.

RESULTS

Fosfomycin maintained activity against 100% of strains of vancomycin-resistant Staphylococcus aureus (VRSA) and linezolid-resistant S. aureus (LRSA), 86% of VISA and 95% of daptomycin-resistant S. aureus (DRSA) strains. The combination of fosfomycin with ceftaroline consistently demonstrated synergy among all 18 isolates against the strains tested. The next most potent combination regimen was linezolid with fosfomycin, which demonstrated synergy in 16 of the 18 strains. Daptomycin demonstrated synergy in only 7 of the 18 strains tested when combined with fosfomycin. Cefazolin demonstrated synergy in 6 of 6 strains and vancomycin demonstrated no interaction in 6 of 6 strains tested.

CONCLUSIONS

Fosfomycin demonstrated excellent activity against MRSA as well as isolates with resistance or reduced activity to other anti-MRSA drugs including vancomycin, daptomycin and linezolid. When combined with linezolid or daptomycin, fosfomycin demonstrated synergy for all or most strains tested. Thus, these combinations may have potential clinical utility when treating patients with serious infections caused by MRSA.

1588. Delafloxacin Activity Against Staphylococcus aureus with Reduced Susceptibility or Resistance to Methicillin, Vancomycin, Daptomycin, or Linezolid

Background

Methods

Results

Conclusion

Disclosures

VISA-Daptomycin non-susceptible Staphylococcus aureus frequently demonstrate non-susceptibility to Telavancin

Telavancin was evaluated against S. aureus isolates with reduced susceptibility to other antimicrobial agents using two broth microdilution methods and Etest® strips. The three methods provided comparable results. Differences in telavancin susceptibility versus non-susceptibility were noted mainly in the VISA-daptomycin non-susceptible group of isolates. In this group the percent susceptibility was 38% for the Etest® method and 50% and 54% for the 2 broth microdilution methods. All differences in susceptibility were within one 2-fold dilution.

Postantibiotic effect and postantibiotic sub-MIC effect of LTX-109 and mupirocin on Staphylococcus aureus blood isolates

The development of new synthetic antimicrobial peptides like LTX-109 provides a new class of drugs for the treatment of Staphylococcus aureus infections. We evaluated LTX-109 and mupirocin for pharmacodynamic parameters against 10 methicillin-resistant S. aureus isolates. The postantibiotic effect (PAE) is defined as the length of time that bacterial growth is suppressed following a brief exposure to an antibiotic. We also determined the sub-MIC effect (SME) which measures the direct effect of subinhibitory levels on strains that have not previously been exposed to antibiotics. The postantibiotic sub-MIC effect (PA-SME) is a combination of the PAE and SME. LTX-109 had an average PAE of 5·51 h vs 1·04 h for mupirocin. The PA-SME of LTX-109 ranged from 2·51 to 9·33 h as the concentration increased from 0·2 to 0·4 times the minimal inhibitory concentration (MIC). The PA-SME range for mupirocin was 0·93-2·58 h. LTX-109, as compared to mupirocin, demonstrated prolonged time of effect for these pharmacodynamic parameters, which supports persistent activity for several hours after the drug is no longer present or is below the MIC. The pharmacodynamic parameters studied here suggest that LTX-109 is less likely than mupirocin to generate resistance to S. aureus.

SIGNIFICANCE AND IMPACT OF THE STUDY

Resistant bacterial infections continue to be a challenge for clinicians. Identification of antibiotics with pharmacodynamic advantages may be beneficial in the treatment of these infections. An antibiotic with a longer postantibiotic effect may be able to be administered less frequently resulting in improved adherence. In this study, a new synthetic antimicrobial peptide, LTX-109, demonstrated a more prolonged time for LTX-109 than mupirocin against methicillin-resistant Staphylococcus aureus.

Emergence of Community-Associated Methicillin-ResistantStaphylococcus aureusInfection Among Patients With End-Stage Renal Disease

Objective.

To evaluate the frequency of infections due to community-associated methicillin-resistantStaphylococcus aureus(CA-MRSA) strains among our patients with end-stage renal disease.

Design.

Prospective observational clinical and laboratory study of patients in 2005. Molecular features of isolates recovered from these patients were compared with those of isolates recovered in 2000 from patients with end-stage renal disease.

Setting.

A 600-bed urban academic medical center.

Patients.

Thirty-two patients with end-stage renal disease and MRSA infection at the time of hospitalization from 2005 were evaluated. For comparison, laboratory analysis was performed for 17 MRSA isolates recovered from patients with end-stage renal disease in 2000.

Results.

The patients from 2005 were more likely than the patients from 2000 to have infection with strains that carried the staphylococcal cassette chromosome (SCC)mectype IV complex (50% vs 11.8%; relative risk, 4.25 [95% confidence interval, 1.17-25.98];P= .012) and the Panton-Valentine leukocidin toxin genes (25% vs 0%;P= .038). Eight patients from 2005 were infected with a strain that is identical to MRSA clone USA300 in terms of molecular type and presence of SCCmectype IV and Panton-Valentine leukocidin genes. Among the patients from 2005, those infected with SCCmectype IV strains (ie, CA-MRSA strains) and those infected with SCCmectype II strains (ie, healthcare-associated MRSA [HA-MRSA] strains) were similar with respect to demographic characteristics, risk factors, and outcomes.

Conclusions.

We documented an increased proportion of infections with CA-MRSA strains, including clone USA300, among our population of patients undergoing dialysis. Patients infected with CA-MRSA strains and HA-MRSA strains were similar with respect to presenting illness and outcomes.

Clinical and Laboratory Features of Community-Associated Methicillin-ResistantStaphylococcus aureus:Is It Really New?

Objective.

To review the epidemiologic and molecular characteristics of community-associated methicillin-resistantStaphylococcus aureus(CA-MRSA) in Detroit, Michigan, to assess the risk factors for infection and the response to therapy.

Design.

Prospective clinical and laboratory study of 2003-2004 CA-MRSA isolates. Molecular features were compared with CA-MRSA isolates from 1980.

Setting.

A 600-bed urban academic medical center.

Patients.

Twenty-three patients with CA-MRSA infections from 2003-2004 were evaluated. In addition, laboratory analysis was performed on 13 CA-MRSA isolates from 1980.

Main Outcome Measures.

Laboratory analysis of isolates included antimicrobial susceptibility testing, pulsed-field genotyping, testing for Panton-Valentine leukocidin (PVL) genes, and staphylococcal cassette chromosomemectyping.

Results.

Patients were predominantly young African American males and presented with skin and soft-tissue infections. All isolates were resistant to erythromycin and highly susceptible to other agents. Patients were generally treated successfully with combination incision and drainage and systemic antibiotics. Among the 23 isolates, 20 (87%) were the same strain. This strain carried the staphylococcal cassette chromosomemectype IV and PVL genes and is genetically identical to USA 300. Thirteen isolates of patients from our community who presented with CA-MRSA infections in 1980 represented a single clone that is unique compared with the 2003-2004 isolates. This strain carried staphylococcal cassette chromosomemectype IVA but did not carry the PVL genes.

Conclusions.

In our community, CA-MRSA is largely due to a single clone with a type IVmecgene and PVL gene. The type IV staphylococcal cassette chromosomemectype can be demonstrated in CA-MRSA isolates from a remote period, suggesting that earlier outbreaks were not related to healthcare exposure.

Prevalence of Colonization With Community-Associated Methicillin-ResistantStaphylococcus aureusAmong End-Stage Renal Disease Patients and Healthcare Workers

Objective.

To evaluate the prevalence, epidemiologic features, and molecular characteristics of colonization with community-associated methicillin-resistantStaphylococcus aureus(CA-MRSA) among hospitalized dialysis patients and their healthcare workers (HCWs).

Design.

Prospective observational clinical and laboratory study of nasal colonization.

Setting.

A 600-bed urban academic medical center.

Subjects.

One hundred twenty hospitalized dialysis inpatients and 100 HCWs.

Results.

Of 120 patients, 40 (33%) were colonized withS. aureus; 26 (65%) of these 40 were colonized with MRSA. Among the 26 MRSA isolates, 10 (38.5%) carried staphylococcal cassette chromosome (SCC)mectype IV (ie, CA-MRSA), and 7 of these 10 carried the genes for the Panton-Valentine leukocidin (PVL) toxin. Patients colonized with healthcare-associated MRSA strains and those colonized with CA-MRSA strains were similar, except for a higher frequency of a history of congestive heart failure among those with healthcare-associated MRSA strains (P= .014). Among 10 patients who presented with or developed anS. aureusinfection while hospitalized, 8 were colonized withS. aureus, 7 with MRSA, and 3 with SCCmectype IV strains. Among 100 HCWs, 31 were colonized withS. aureus, including 6 with MRSA; 2 of the MRSA isolates belonged to CA-MRSA strains, and soft-tissue infections were reported in one of the HCWs and in the family member of the other HCW colonized with these strains.

Conclusions.

There is a high rate of colonization with MRSA and CA-MRSA among hospitalized dialysis patients and their HCWs. As other studies have found, it appears that individuals are being colonized with both CA-MRSA strains and healthcare-associated MRSA strains.

Ceftaroline-heteroresistant Staphylococcus aureus

Heteroresistance refers to the presence, within a large population of antimicrobial-susceptible microorganisms, of subpopulations with lesser susceptibilities. Ceftaroline is a novel cephalosporin with activity against methicillin-resistant Staphylococcus aureus (MRSA). The aim of this study was to detect the prevalence of ceftaroline heteroresistance in vitro in a select group of S. aureus strains. There were 57 isolates selected for evaluation, 20 MRSA, 20 vancomycin-intermediate S. aureus (VISA), 7 daptomycin-nonsusceptible S. aureus (DNSSA), 6 linezolid-nonsusceptible S. aureus (LNSSA), and 4 heteroresistant VISA (hVISA) isolates. MICs and minimal bactericidal concentrations were determined using the broth microdilution method according to CLSI guidelines. All of the isolates were analyzed by pulsed-field gel electrophoresis. The staphylococcal cassette chromosome mec element (SCCmec) types were determined by a multiplex PCR. Population analysis profiles (PAPs) were performed to determine heteroresistance for all of the isolates using plates made by adding various amounts of ceftaroline to brain heart infusion agar. The frequencies of resistant subpopulations were 1 in 10(4) to 10(5) organisms. We determined that 12 of the 57 (21%) isolates tested were ceftaroline-heteroresistant S. aureus (CHSA). CHSA occurred among strains with reduced susceptibilities to vancomycin, daptomycin, and linezolid but occurred in none of the USA-300 isolates tested. Evaluation of the heteroresistant strains demonstrated that the phenotype was unstable. Further studies are needed to determine whether CHSA has a role in clinical failures and to determine the implications of our study findings.

In vitro activities of LTX-109, a synthetic antimicrobial peptide, against methicillin-resistant, vancomycin-intermediate, vancomycin-resistant, daptomycin-nonsusceptible, and linezolid-nonsusceptible Staphylococcus aureus

LTX-109 and eight other antimicrobial agents were evaluated against 155 methicillin-resistant Staphylococcus aureus (MRSA) isolates, including strains resistant to vancomycin and strains with decreased susceptibility to daptomycin and linezolid, by microdilution tests to determine MICs. Time-kill assays were performed against representative MRSA, vancomycin-intermediate S. aureus (VISA), and vancomycin-resistant S. aureus (VRSA) isolates. LTX-109 demonstrated a MIC range of 2 to 4 μg/ml and dose-dependent rapid bactericidal activity against S. aureus. This activity was not influenced by resistance to other antistaphylococcal agents.

In vitro susceptibilities and molecular analysis of vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus isolates

BACKGROUND

There is increasing frequency of vancomycin-intermediate and -resistant Staphylococcus aureus (VISA and VRSA) isolates identified in clinical practice. There are limited reports evaluating susceptibility patterns and molecular characteristics of these strains.

METHODS

Laboratory analysis was performed on 13 VRSA and 33 VISA isolates, including susceptibility testing by broth microdilution, detection of Panton-Valentine leukocidin (PVL) genes, arginine catabolic mobile element (ACME), and staphylococcal cassette chromosome mec typing using polymerase chain reaction. Strain typing using pulsed-field gel electrophoresis (PFGE) was performed on VRSA isolates.

RESULTS

Telavancin, linezolid, tigecycline, and minocycline were active against >90% of VISA isolates, while >90% of VRSA isolates were susceptible to ceftaroline, daptomycin, linezolid, minocyline, tigecycline, rifampin, and trimethoprim/sulfamethoxazole. There were no VISA or VRSA isolates that carried PVL genes or ACME, and most strains (69.8%) were staphylococcal cassette chromosome mec type II. VRSA isolates were predominantly related to USA100 (53.8%) and none were related to USA300 or USA400.

CONCLUSIONS

A large number of available antimicrobial agents retain very good in vitro activity against VRSA and VISA isolates. The present isolates appear to be derived from healthcare-associated strains based on the absence of features associated with community-associated strains, and VRSA isolates are polyclonal by PFGE.

In vitro activity of ceftaroline against community-associated methicillin-resistant, vancomycin-intermediate, vancomycin-resistant, and daptomycin-nonsusceptible Staphylococcus aureus isolates

This study assessed the in vitro activities of ceftaroline and five comparator agents against a collection of Staphylococcus aureus isolates. Ceftaroline demonstrated potent activity against community-associated methicillin-resistant S. aureus (CA-MRSA) isolates and showed bactericidal activity against vancomycin-intermediate S. aureus (VISA), vancomycin-resistant S. aureus (VRSA), heteroresistant VISA (hVISA), and daptomycin-nonsusceptible S. aureus (DNSSA) isolates. Ceftaroline may represent a bactericidal treatment option for infections caused by these pathogens.

Detection of Streptococcus pneumoniae colonisation in respiratory tract secretions of military personnel

Respiratory tract infections with Streptococcus pneumoniae are an important cause of morbidity and mortality among military personnel. A sensitive method is needed to determine the prevalence of S. pneumoniae colonisation in respiratory secretions, as well as its role in pneumonia without an established aetiology. This study investigated the efficacy of two PCR assays in screening military personnel for S. pneumoniae colonisation. Nasopharyngeal swabs were obtained from 200 military personnel and tested for S. pneumoniae by culture and PCR. S. pneumoniae was cultured from three (1.5%) of the 200 samples. PCR for the lytA gene detected S. pneumoniae in 11% of the samples, while PCR for the pneumolysin gene detected S. pneumoniae in 3% of the samples. The sensitivity and negative predictive values were 100% for both PCR assays when compared to culture; the specificity and positive predictive values for the lytA PCR were 90.4% and 13.6%, respectively, compared with 98.5% and 50%, respectively, for the pneumolysin gene PCR. It was concluded that respiratory tract colonisation of military personnel with S. pneumoniae can be identified rapidly and reliably by PCR assays. The use of this technique may greatly enhance the ability to identify a microbial aetiology for pneumonia when compared with conventional culture methods.

Comparative activity of telavancin against isolates of community-associated methicillin-resistant Staphylococcus aureus

OBJECTIVES

This study compared the activity of telavancin, a novel multivalent lipoglycopeptide with rapid bactericidal activity, with those of five standard antibiotics for methicillin-resistant Staphylococcus aureus (MRSA) against isolates of community-associated MRSA (CA-MRSA).

METHODS

Microdilution tests performed according to CLSI guidelines using cation-adjusted Mueller-Hinton broth were used to determine the MIC values of telavancin, quinupristin/dalfopristin, vancomycin, trimethoprim/sulfamethoxazole, linezolid and daptomycin versus 60 CA-MRSA isolates. MBC values of telavancin were determined according to CLSI guidelines and American Society for Microbiology standards. PFGE was performed using the restriction enzyme SmaI. Samples from three predominant pulsed-field types were typed by multilocus sequence typing. Staphylococcal cassette chromosome mec typing was determined by multiplex PCR. The Panton-Valentine leucocidin (PVL) genes (lukS-PV and lukF-PV) were identified by PCR.

RESULTS

The telavancin MIC90 and MBC90 values for this collection of 60 CA-MRSA isolates were 0.5 and 1 mg/L, respectively, with MIC and MBC values both ranging from 0.25 to 1 mg/L. Telavancin was found to be bactericidal in this study, as its MBC was no more than 2-fold higher than its MIC for all CA-MRSA isolates tested except one. (A single isolate yielded an MBC/MIC ratio of 4.) PVL- and non-PVL-producing strains demonstrated similar susceptibility to telavancin and comparator agents.

CONCLUSIONS

Based on in vitro activity, telavancin should be an effective agent against CA-MRSA.

Recurrence of primary sclerosing cholangitis in patients after liver transplantation

BACKGROUND

Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease that progresses to end-stage liver disease. There are several specific problems related to the posttransplantation period in these patients. The aim of this study was to analyze a single center experience with 17 orthotopic liver transplantations (OLT) due to PSC.

PATIENTS AND METHODS

Seventeen patients were included (10 men, 7 women). Actuarial patient and graft survival rates and the incidence of recurrent sclerosing cholangitis were determined at 1, 5, and 7 years.

RESULTS

Fifteen patients received single grafts, whereas two patients required retransplants. Patients received either cyclosporine (n = 7) or tacrolimus (n = 10) based immunosuppression. The 1-, 5-, and 7-year patient survival rates were 80%, 60%, and 60%, respectively, whereas the graft survival rates were 88%, 65%, and 65%, respectively. Two patients had cholangiocarcinomas (CCA) diagnosed during OLT; both recurred within 6 months and had a fatal outcome. Two patients (12%) developed recurrent sclerosing cholangitis, as assessed by liver histology and imaging of biliary tree.

CONCLUSIONS

Liver transplantation provides good patient and graft survival rates in cases affected with PSC. CCA is associated with poor recipient survival. Recurrent PSC occurs in approximately 12% of cases but does not significantly affect patient survival.

Community-associated methicillin-resistant Staphylococcus aureus causing chronic pneumonia

A young woman presented with pneumonia of a 3-month duration with predominantly nodular pulmonary infiltrates. Methicillin-resistant Staphylococcus aureus was identified in multiple cultures of sputum specimens. According to findings of pulsed-field gel electrophoresis, the isolate was identical to USA 300 and carried a type IV Staphylococcus cassette chromosome mec type IV gene and the genes for Panton-Valentine leukocidin.

Antimicrobial activity and a comparison of published pharmacodynamics of gemifloxacin and eight fluoroquinolones against Streptococcus pneumoniae

Gemifloxacin was evaluated for its in vitro activity and was compared with eight fluoroquinolones. Pharmacodynamic comparisons were made based on published pharmacokinetic information. Gemifloxacin demonstrated excellent in vitro activity (minimum inhibitory concentration necessary to inhibit 90% of the strains tested, MIC90 = 0.03 mg/L (range 0.0019-0.03 mg/L)) against 199 strains of Streptococcus pneumoniae. Its activity was not influenced by penicillin or ciprofloxacin non-susceptibility. Gemifloxacin demonstrated excellent pharmacodynamic parameters, with a Cmax/MIC90 of 67 (where Cmax is the peak serum level) and an AUC/MIC90 of 297 (where AUC is the area under the curve). Compared with the other eight fluoroquinolones tested, gemifloxacin demonstrated the best in vitro activity and Cmax/MIC90.

Biliary tract complications following liver transplantation

INTRODUCTION

Biliary tract complications, which occur in 5.8% to 24.5% of adult liver transplant recipients, remain one of the most common problems following transplantation. The aim of this study was to evaluate these problems and analyze methods of treatment.

MATERIAL AND METHODS

From 1989 to 2003, 36 (18.7%) among 193 patients who underwent orthotopic liver transplantations in our center developed biliary complications. Biliary strictures that developed in 18 cases (9.3%) were the most common complications. Clinical manifestations of strictures developed at 2 to 24 months after transplantation. Bile leaks occurred in 10 patients (5.2%), and were diagnosed in along the T-tube 4 cases and was not accompanied by any clinical manifestation. Bile leak to the peritoneum after T-tube removal occurred in 2 patients (1.1%). Solitary gallstone formation in one case (0.5%) was removed with the use of ECPW. One patient required retransplantation within 3 months after transplantation, because of the most severe complication-ischemic necrosis of biliary tract.

RESULTS

Uneventful recovery was achieved in 34 patients in the analyzed group (94.4%). There was no case of recurrence during outpatient follow up. Two patients died in late follow-up of unrelated causes: namely, gastrointestinal bleeding due to a duodenal ulcer and multi-organ failure (MOF) due to a third severe episode of acute liver transplant rejection.

CONCLUSIONS

Biliary complications remain an important problem in liver transplantation. Endoscopic and radiologic management are effective in the majority of cases. Surgical intervention is obligatory in selected cases.

Vascular complications after liver transplantation

Vascular complications following liver transplantation is reviewed based upon literature data and our own results. Our study conclusions are mostly based on literature data, because our center does not have the liver transplantation experience of other centers worldwide. Thus, we may conclude, that the number and character of complications does not differ from those reported by other centers. The enbloc technique used in liver harvesting minimizes the risk of arterial damage in case of vascular anomalies. Recipient retransplantation is the most effective treatment method in cases of hepatic arterial occlusion. Doppler ultrasound examinations are effective to monitor vascular blood flow in the transplanted liver.

Apoptosis phenomenon in the selected neoplasms of the glial origin

Gliomas cause a therapeutic problem because of their localization and asymptomatic growth in the initial phase. Neoplastic growth is connected with disturbance between proliferation and apoptosis. In the study, we assessed the Bcl-2 family proteins involved in apoptosis in gliomas. The study comprised 61 patients with gliomas and based on tissue material sent for the diagnosis. Apoptosis was assessed in various types of gliomas and was defined by the apoptotic index (IA) and shown immunohistochemically with using Bcl-2, Bax and Bcl-x antibodies. The data were statistically analyzed. We found an increased percentage of the Bax (+) cells in less matured gliomas. A reverse dependence was revealed for Bcl-x. It was found that, probably in gliomas, the assessment of the Bcl-2 family proteins may serve only as an additional parameter for the evaluation of the disease course and the therapeutic success.

Expression of Ki-67, PCNA and MPM2 antigens in follicular cells of the thyroid gland after iodotherapy

Hyperfunctional nodular goitre is the most common thyroid non-neoplastic condition in endemic areas. Iodotherapy is the basic method in thyroid gland hyperfunction treatment. The aim of the study was to evaluate proliferation of thyroid follicular cells in nodular goitre after iodotherapy. The study was carried out on 32 women, 30-76 years old. Cytological and immunohistochemical evaluations were based on the material, obtained by Fine-Needle Aspiration Biopsy (FNAB). Proliferative activity was immunohistochemically assessed. The influence of radioiodine on thyroid follicular cells was evaluated as a difference between the proliferation of follicular cells before and after its application. It was concluded that the proliferative activity of thyroid follicular cells decreased considerably after radioiodine therapy.

Intracerebral varicella-zoster virus reactivation in congenital varicella syndrome

Patients with congenital varicella syndrome (CVS) typically present with clinical symptoms consisting of skin lesions, neurological defects, eye diseases, and/or limb hypoplasia. In rare cases, isolated manifestations in the brain or eye have been reported. The varicella-zoster virus (VZV), as the causative agent of CVS, could only be detected in a few infants with CVS. In addition, there is little in the literature on antiviral treatment of infants born with signs of CVS. We report a case of CVS in a male infant who presented with generalized clonic cerebral seizures at age 4 months. An endogenous intracerebral viral reactivation following intrauterine VZV infection was assumed. After the diagnosis was confirmed virologically, acyclovir was administered intravenously for 10 days and afterwards orally for 3 weeks. This antiviral treatment was aimed at preventing progression of the disease. We concluded from this case that infants with intrauterine VZV infection can suffer intracerebral VZV reactivations that require antiviral treatment.

Results of liver transplantation according to indications for orthotopic liver transplantation

OBJECTIVE

This study assessed the results of liver transplantation in patients with a variety of different indications.

METHODS

From 1989 to April 2003, 209 orthotopic liver transplantations (OLTx) were performed on 196 patients, including 178 cases. The diagnoses were: PBC (n = 34); PSC (n = 13); elective postinflammatory cirrhosis in the course of hepatitis C (n = 29); hepatitis B (n = 16); postalcoholic cirrhosis (n = 23), autoimmune cirrhosis (n = 11); Wilson's disease (n = 6); cirrhosis of unknown etiology (n = 10); secondary biliary cirrhosis (n = 5); Budd-Chiari syndrome (n = 6); and benign liver neoplasms (n = 7).

RESULTS

The 3-year survival rate in the group of patients transplanted electively was 74.1%. In other groups it was: PBC, 91.4%; PSC, 69.2%; hepatitis C, 69.6%; hepatitis B, 55.5%; postalcoholic cirrhosis, 80%; autoimmune cirrhosis, 81.8%; Wilson's disease, 57.1%; secondary biliary cirrhosis, 40%; Budd-Chiari syndrome, 66.6%; hemochromatosis, 100%; benign neoplasms of the liver, 87.5%; and liver cysts, 100%.

CONCLUSIONS

Results of liver transplantation were closely related to the urgency of the procedure. Better results were achieved in patients operated upon routinely compared with in those operated upon emergently (74.1% vs 50%). The best results of liver transplantation were achieved in patients transplanted on a routine basis with a diagnosis of PBC (91.4%), autoimmunologic cirrhosis (81.1%), postalcoholic cirrhosis (80%), or hemochoromatosis (100%). Patients with liver insufficiency due to hepatitis B and Wilson's disease have an increased risk of graft destruction, and the rate of survival in these patients is significantly lower than in other patients.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.

Comparison of the results of liver transplantation for elective versus urgent indications

The authors present an analysis of early and remote liver transplantation outcomes related to the presence of emergent indications among 196 of the 209 operations performed from 1989 to April 2003; namely 178 elective and 18 emergent transplantations. Perioperative mortality was 15%. The survival rate during the first 12 months was 79.8% and within 3 years 73.5% among patients operated on an elective basis (UNOS 3 and 2B). In contrast, patients with acute liver failure (UNOS 1 and 2A) showed rates of 45%, 50%, and 47%, respectively. Liver transplant outcomes depend primarily on the urgency of an operation. Longterm results are much better among patients operated on electively. Liver transplantation in patients with acute hepatic insufficiency is burdened with a high 45% mortality.

Biochemical assessment of the early liver graft function in relation to selected donor parameters

The aim of this study was to assess the usefulness of liver grafts procured from "marginal donors." Among 62 liver transplants in 2002, almost half were harvested from donors who were not deemed acceptable by other transplant units. The authors compared the data concerning the donor's status with the function of the transplanted liver. The relations between individual parameters were estimated, as well as the differences between two groups of recipients: those who received a graft from the "poorer" donors versus those who received "better" grafts. Regardless of the relations between particular parameters a statistical analysis revealed that differences of liver function that were detected during the first 5 days after transplantation disappeared thereafter.

Resistance of gram-positive pathogens to antibiotics is a therapeutic challenge after liver transplantation: clinical experience in one center with linezolid

BACKGROUND

Orthotopic liver transplantation has become an established therapeutic option for a large variety of fulminant and chronic liver diseases. Postoperative infections are the major cause of morbidity and the leading cause of mortality. The microbes responsible for these severe infections are predominantly gram-positive.

METHODS

This article reviews results of linezolid therapy based on the clinical characteristics, microbial features, and outcomes of severe bacterial infections due to known or suspected resistant gram-positive species in selected liver allograft recipients.

RESULTS

Among the 7 patients who received linezolid, methacillin-resistant Staphylococcus aureus. was isolated from 3, no pathogen from 2 patients, and serious pulmonary infection in 2 patients, 1 of whom had to be reintubated due to of respiratory failure. Cholangitis observed in 5 of 7 patients was caused by enterococci and staphylococci with septicemia in 1 subject. All patients demonstrated clinical improvement; microbiological eradication was observed in 4 patients. The majority of reported adverse events were mild or moderate in intensity. No potential drug interactions were observed between linezolid and concomitant medication.

CONCLUSIONS

In the present study, linezolid proved to be effective and well tolerated. In summary, linezolid may represent an effective and safe antimicrobial agent for the treatment of infections due to susceptible and resistant gram-postive bacteria after solid organ transplantation.

Changing epidemiology of community-onset methicillin-resistant Staphylococcus aureus bacteremia

OBJECTIVES

To review cases of community-onset Staphylococcus aureus bacteremia and to evaluate whether the risk factors and epidemiology of methicillin-resistant S. aureus (MRSA) bacteremia have changed from early reports.

DESIGN

Retrospective case-comparison study of community-onset MRSA (n = 26) and methicillin-susceptible S. aureus (MSSA) (n = 26) bacteremias at our institution.

SETTING

A 600-bed urban academic medical center.

PATIENTS

Twenty-six patients with community-onset MRSA bacteremia were compared with 26 patients with community-onset MSSA bacteremia. Molecular analysis was performed on S. aureus isolates from the 26 MRSA cases as well as from 13 cases of community-onset S. aureus bacteremia from 1980 and 9 cases of nosocomial S. aureus bacteremia from 2001.

RESULTS

The two groups were similar except that patients with MRSA bacteremia were more likely to have presented from a long-term-care facility (26.9% vs 4%; P = .05) and to have had multiple admissions within the preceding year (46% vs 15%; P = .03). Clamped homogeneous electric fields analysis of MRSA isolates from 1982 revealed predominantly that one clone was the epidemic strain, whereas there were 14 unique strains among current community-onset isolates. Among current nosocomial isolates, 3 patterns were identified, all of which were present in the community-onset cases.

CONCLUSIONS

Previously described risk factors for MRSA acquisition may not be helpful in predicting disease due to the polyclonal spread of MRSA in the community. Unlike early outbreaks of MRSA in patients presenting from the community, current acquisition appears to be polyclonal and is usually related to contact with the healthcare system.

Assessment of early graft function in relation to different preservation fluids--preliminary results

The parameters of transplanted liver functions were exposed to a retrospective analysis during the past year. A group of 51 patients out of 223 were thoroughly examined, all of them having undergone orthotopic liver transplant in Department of General, Transplant and Liver Surgery, Medical University of Warsaw until 1.09.2003. With transplants, two types of preservation fluids: UW (Viaspan) and Celsior were used alternatively. Liver function was assessed on the basis of the clinical feature and biochemical data. The results obtained were statistically verified. The way of fluid perfusion during the operation and the rinsing effectiveness were also evaluated, additionally the level of marked K during the reperfusion was checked. There were no statistically significant differences noticeable between both groups of recipients. Among all the liver and kidneys effectiveness parameters assessed with the recipients after OLTx, the considerable difference statistically, was visible only with the levels of AspAt, AlAt, INR and APTT during the first days and nights after the operations. Later the difference was gradually disappearing. However, in accordance with the harvesting teams' opinions, the usage of Celsior, owing to lower viscosity, allowed for faster and more exact blood rinsing from a vascular bed of the organ transplanted. The organ's even penetration was also possible. The lack of necessity to use additional stabilizers also simplified radically the harvesting technique. Celsior--the preservation fluid used in the authors' clinic meets all the requirements necessary to efficacious preservation and storage of a to be transplanted liver.

Broad-range bacterial polymerase chain reaction for early detection of bacterial meningitis

The diagnosis of bacterial meningitis often depends on isolation of bacteria on culture, which may take 24-48 h. DNA amplification techniques could provide rapid diagnosis, which would guide the clinician in antimicrobial therapy decisions. This study determined the clinical utility of polymerase chain reaction (PCR) for the diagnosis of meningitis with use of a broad range of bacterial primers. Seventy-four cerebrospinal fluid specimens obtained from 70 patients were subjected to PCR with use of primers derived from conserved regions of the bacterial 16S RNA gene. The test characteristics for the broad-range bacterial PCR were as follows: sensitivity, 100%; specificity, 98.2%; positive predictive value, 94.4%; and negative predictive value, 100%. Broad-range bacterial PCR may be useful for excluding the diagnosis of meningitis, and the results may influence the decision to initiate or discontinue antimicrobial therapy.

Leitvenenschädigung durch Verödungsbehandlung?

Ziel: Die Haupthypothese, ob es nach Verödungsbehandlung häufiger zur Leitveneninsuffizienz kommt, als es dem Spontanverlauf der primären Varikose entspricht, sollte geklärt werden. Weiter sollte geprüft werden, ob eine Verödungstherapie rascher und ausgeprägter zur Dilatation der Vena femoralis communis führt oder komplikationsträchtiger ist als die operative Varizenausschaltung oder die rein konservative Behandlung, und ob eine intensive, ausgedehnte Sklerotherapie mehr Komplikationen aufweist als eine begrenzte (Nebenhypothesen). Methodik: In einer retrospektiven Analyse einer Zufallsstichprobe wurden 198 Patienten durch einen externen Untersucher rekrutiert und in folgende, gut vergleichbare, gleich große Gruppen eingeteilt: Patienten nur mit Verödungstherapie (a), Patienten nach Varizenoperation (b), Kontrollgruppe nur mit Kompressionstherapie und Allgemeinmaßnahmen (c). Der Beobachtungszeitraum betrug mindestens 12, im Mittel 46 Monate. Ergebnisse: Nach Sklerosierungsbehandlung trat weder eine Klappeninsuffizienz im Bereich der Leitvenen noch eine Dilatation der Vena femoralis communis rascher oder häufiger auf als in den Vergleichsgruppen mit operativer oder rein konservativer Therapie. Die Anzahl bedeutsamer Komplikationen war gering; bei operativer Behandlung waren die Komplikationen häufiger und schwerwiegender. In der Kontrollgruppe kam es in zwei Fällen zu Beinvenenthrombose mit Lungenembolie. Es ergab sich ein guter Effekt der varizenausschaltenden Maßnahmen: Die Patienten waren in >80% der Fälle mit dem Ergebnis zufrieden. Schlussfolgerung: Verödungs- und operative Behandlung von Varizen sind ausreichend sicher und effektiv. Wichtig für die Indikationsstellung zu den geeigneten Therapiemaßnahmen und zur Verlaufsbeurteilung ist eine adäquate morphologische und funktionelle Primärdiagnostik mit entsprechenden Verlaufskontrollen.

[Liver failure during the course of treatment of patients with bleeding esophageal varices]

Based on the bibliography and 30 years of experience, we present a current opinion on the treatment of patients with increasing liver failure in the course of the treatment of patients with bleeding esophageal varices.

Immature hepatic tumor of bimodal differentiation in a young adult patient: a novel lesion expressing beta-catenin and mimicking a distinct phase of hepatogenesis

PATIENT AND METHODS

A large right-sided liver tumor was incidentally discovered and totally resected in a 21-year-old female patient without chronic liver disease. Histopathologic examination revealed that this malignant tumor does not fit any of the known types of primary liver tumors reported thus far.

RESULTS

The lesion chiefly consisted of numerous solid nests composed of immature epithelial cells disclosing a marker profile typical for hepatocytes and strongly expressing beta-catenin. These nests were tightly associated with abnormal duct-like profiles exhibiting features of bile duct cells.

CONCLUSIONS

The finding of numerous neoplastic hepatobiliary units ('liverlets') suggests that this tumor may mimic a distinct developmental phase of hepatogenesis close to ductal plate formation.

Antimicrobial activity of moxifloxacin, gatifloxacin and six fluoroquinolones against Streptococcus pneumoniae

The in vitro and pharmacodynamic effects of moxifloxacin and gatifloxacin against Streptococcus pneumoniae were compared with six other fluoroquinolones. Organisms included penicillin-susceptible (54) and penicillin-non-susceptible (145) isolates from 1998-1999. Moxifloxacin and clinafloxacin demonstrated the greatest in vitro activity, with MIC90s of 0.13 mg/L, followed by trovafloxacin, grepafloxacin > gatifloxacin, sparfloxacin > levofloxacin > ciprofloxacin. There was no difference in fluoroquinolone activity between penicillin-susceptible and -non-susceptible strains. Pharmacodynamic analysis using published pharmacokinetic information indicates that all the agents tested except ciprofloxacin had an AUC/MIC90 > 30, with moxifloxacin having the greatest free-drug availability.

Correlation between the haemodynamics of portal collateral circulation and the incidence of esophageal bleeding in patients with portal vein thrombosis--a preliminary report

The aim of this study was to determine a correlation between the haemodynamics of portal collateral circulation (PCC) and the incidence of bleeding episodes. The prospective analysis included 17 patients with portal hypertension resulting from prehepatic block but without history of oesophageal bleeding. Every two months the changes in PCC and incidence of oesophageal bleeding were evaluated. The follow-up ranged from 3 to 12 months. The statistical correlation between the portal haemodynamic disorders and the tendency to bleed was investigated. Variceal bleeding occurred in 6 patients during the time of observation, mostly in patients with development of hepatofugal PCC. Authors suggest that the development of hepatofugal PCC is the main factor of variceal bleeding in patients with portal vein thrombosis (PVT).

Intrahepatic portosystemic shunt in treatment of complications of portal hypertension

BACKGROUND

The aim of the paper is to present the role of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of portal hypertension complications such as variceal bleeding and persistent ascites.

MATERIAL AND METHODS

Between June 1992 and December 2000, 56 patients with portal hypertension developed in the course of hepatic cirrhosis were qualified for TIPS. The indications for TIPS included esophageal variceal bleeding, recurrent despite endoscopic treatment (N-40), active esophageal variceal hemorrhages in which traditional methods used to stop the bleeding proved ineffective (N-8) and ascites failing to respond to high doses of diuretic agents (N-8). The studied group consisted of 30 females and 26 male patients aged from 17 to 68 (mean age 52 yrs). According to Child-Pugh surgical risk classification, 26 patients belonged to group B, and 30 to group C.

RESULTS

In 50 patients (83.5%) an intrahepatic shunt was formed and the stent(s) implanted. In 42 cases (75%), long-lasting patency of the shunt was obtained and esophageal variceal bleeding was stopped. Active esophageal variceal hemorrhages were stopped in all the cases. The remission of massive ascites and hepatorenal syndrome was obtained in 7 out of 8 patients.

CONCLUSIONS

TIPS is a non-surgical method relieving portal hypertension in patients with variceal hemorrhages recurrent despite endoscopic treatment. Very good results were also obtained in the cases with active variceal hemorrhages. TIPS has proved to be an effective method of treatment in the patients with massive ascites and hepatorenal syndrome.

Imaging techniques in patients with biliary obstruction

The most frequent causes of cholestasis include choledocholithiasis and neoplasms (pancreatic head carcinoma, ampullary carcinoma, cholangiocarcinoma). The authors discussed imaging modalities currently applied in the diagnostics of patients with suspected obstruction biliary tract obstruction. Special attention was paid to the efficacy of these techniques in detecting the obstruction and determining its level and nature. In general, US or CT are first performed in patients with cholestasis. The use of percutaneous cholangiography and retrograde cholangiopancreatography is often limited to therapeutic interventions. Magnetic resonance offers images similar to both conventional cholangiography and computed tomography. This technique offers complex evaluation of bile ducts and other abdominal organs.

Liver transplantation in the experience of the centre commencing the program

From 1989 to 1999, 43 orthotopic liver transplantations (OLT) in 40 patients (3 retransplantations) were performed in our Department. The most common indications for OLT were noninflammatory, primary cholestatic liver diseases and postinflammatory liver cirrhosis. Fourty OLT's were done for elective indications, three--on emergency basis, because of fulminant liver failure. The majority of transplantations was performed with classical technique with the excision of retrohepatic vena cava and routine use of the extracorporeal veno-venous bypass. Only in 4 patients the piggyback technique was used and performed without temporary portocaval anastomosis. All 3 patients transplanted for fulminant liver failure died in the perioperative period. Twenty four patients are still alive and well, the longest period of observation exceeding 5 years.