Outbreak of ertapenem-resistant Enterobacter cloacae urinary tract infections due to a contaminated ureteroscope.

BACKGROUND: Outbreaks of urinary tract infections (UTIs) due to contaminated ureteroscopes have been rarely reported. AIM: To report such an outbreak at a regional teaching hospital in southern Taiwan. METHODS: From October to December 2010, ertapenem-resistant Enterobacter cloacae were identified from urine cultures of 15 patients who had undergone ureteroscopy prior to the infection. Three batches of surveillance cultures were obtained from the environmental objects and healthcare workers related to the procedures. Pulsed-field gel electrophoresis (PFGE) was used for bacterial typing. Antimicrobial susceptibility was assessed by disc diffusion and E-test methods. Polymerase chain reaction and sequencing were used to analyse ß-lactamase genes. FINDINGS: A total of 70 specimens were obtained during the first surveillance operation. One ertapenem-resistant E. cloacae was isolated from a ureteroscope. Although the disinfection protocols for ureteroscopes were revised and implemented, seven additional UTI cases were identified thereafter. The pathogen was identified from two subsequent surveillance cultures and was not eliminated until ethylene oxide sterilization was added to the disinfection protocol. PFGE revealed that all 15 isolates from the patients and the three isolates from the ureteroscope shared a common pattern with minor variance. Most isolates were resistant to gentamicin, levofloxacin, ceftriaxone, ceftazidime, and ertapenem. All isolates were susceptible to amikacin, imipenem, and meropenem. SHV-12 and IMP-8 genes were simultaneously identified in 16 of the 18 isolates. CONCLUSION: The outbreak of ertapenem-resistant E. cloacae was caused by a contaminated ureteroscope and was terminated by the implementation of a revised disinfection protocol for ureteroscopes.

Change of circulating thyroid autoantibody titers in Graves' hyperthyroidism after antithyroid drugs therapy.

Parallel measurements of circulating thyroglobulin (Tg), microsomal [TPO(mic)] and TSH-receptor antibodies [TSH-R(rr)] were performed in 30 cases of Graves' hyperthyroid patients who received antithyroid drug (ATD) therapy for 2.8 +/- 1.7 years (range: 0.5-5.0 years). Before ATD therapy, positive Tg, TPO(mic) and TSH-R(rr) antibodies were found in 33.3%, 83.3% and 86.7% of our patients with Graves' disease, respectively. The titers of Tg and TPO(mic) antibodies remained unchanged in most patients after ATD treatment. However, the TSH-R(rr) antibody titers decreased in 46.7%, elevated in 26.7% and unchanged in 26.7% after ATD therapy. Six cases got long-term remission. Measurements of Tg and TPO antibodies have no value in forecasting the outcome of the disease. The change of circulating TSH-R(rr) antibody from positive to negative is more predictive of remission after ATD therapy than the decrease of thyrotropin-binding inhibiting immunoglobulin index only. However, the former change indicating a persistent remission is not certain.

Changes in serum thyroid hormone and thyroglobulin levels after surgical treatments for toxic and non-toxic goiter.

We assessed changes in serum total tri-iodothyronine (TT3), total thyroxine (TT4), free thyroxine (FT4), reverse tri-iodothyronine (rT3), thyroid stimulating hormone (TSH), and serum thyroglobulin (hTg) levels in 20 patients with toxic diffuse goiter who received subtotal thyroidectomy after metabolic control with antithyroid drugs and 22 patients with non-toxic solitary nodular goiter who received lobectomy only. In the first 2 days postoperatively the toxic diffuse goiter group had approximately a 50% decrease in the mean serum TT3 concentration, and a 28% decrease in the mean serum TT4 concentration. In the same period, the non-toxic nodular goiter group had approximately a 30% decrease in mean serum TT3 concentration, and a 15% decrease in mean serum TT4 concentration. The toxic diffuse goiter group and the non-toxic nodular goiter group each had transient elevations of the mean serum rT3 concentration, amounting to 34% and 48% respectively. Neither group had any change in the mean serum FT4 level, while both showed a several-fold elevation of serum hTg. At the 6th week postoperatively in both groups, the mean serum TT3 level had returned to the preoperative value, the mean serum TT4, rT3 and hTg levels were significantly lower than preoperative values, and the mean serum FT4 level remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of recurrent thyroid cysts by injection of tetracycline or minocycline.

We analyzed the effects of tetracycline hydrochloride or minocycline hydrochloride sclerotherapy on 66 recurrent thyroid cysts. All were hemorrhagic lesions except one serous cyst; cytologic study showed all were benign. On average, three treatments were given until resolution or the patient became unavailable for follow-up. The cumulative frequency of cyst disappearance was 33%, 45%, 52%, and 59% after 1, 2, 3, and 4 treatments. Five additional patients had cyst resolution after six to 19 treatments, and the serous lesion did not resolve. Cysts requiring more than two treatments were larger at presentation than those resolving after one or two treatments. Side effects in 179 treatments were local pain lasting ten to 20 minutes in 4.5%, radiated pain lasting one to two hours in 4.5%, fatigue lasting one to two days in 3.9%, and a febrile sensation lasting one to two days in 2.8%. Hemorrhagic thyroid cysts can usually be cured by repeated tetracycline or minocycline sclerotherapy with tolerable side effects.