Clinical characteristics of Group G streptococcal bacteremia in Taiwan.

The results of this retrospective study showed that Group G streptococcal bacteremia was an acute febrile disease with low mortality. Most patients were > 60 y old but there was a strong association between age < 60 y and malignancy. Cases clustered in summer and the most common port of entry was the skin.

In vitro activity of 19 antimicrobial agents against enterococci from healthy subjects and hospitalized patients and use of an ace gene probe from Enterococcus faecalis for species identification.

We tested 165 enterococcal isolates, biased toward vancomycin resistant (VR) isolates, collected during recent years from fecal samples of healthy subjects and clinical specimens of hospitalized patients (mostly from United States and some from Europe) for susceptibility to 19 antimicrobials. Nosocomial isolates, whether VR or not, were more often highly resistant to aminoglycosides and clindamycin than fecal isolates from healthy community volunteers and more often resistant to erythromycin, chloramphenicol, trimethoprim, levofloxacin and, for E. faecium, ampicillin (93 vs. 0%). Resistance rates were similar between nosocomial and community-fecal isolates for minocycline, rifampin and quinupristin-dalfopristin (Q-D). None of the 165 enterococci tested hybridized with aph(2'')-Ic and aph(2'')-Id probes for recently described gentamicin resistance genes and 37 of the 39 isolates with high level resistance (HLR) to gentamicin hybridized with an intragenic aac(6')-aph(2'') probe. Of the two newer drugs tested, daptomycin MIC90s were 0.25 microg/mL for E. faecalis and 1 microg/mL for E. faecium, regardless of their vancomycin resistance level or source. For Q-D, none of 28 E. faecium from community based healthy subjects in the USA and 7 of 66 E. faecium from hospitalized patients in the United States were resistant. Among these 7 Q-Dr United States isolates and 7 Q-Dr isolates from Europe (MICs of Q-D of 4-8 microg/mL), none hybridized with vat(D) (formerly satA) and vat(E) (formerly satG) DNA probes, indicating the involvement of other mechanism/s of resistance in these isolates. We also demonstrated that an intragenic probe of the gene ace from E. faecalis showed specific hybridizations to all E. faecalis isolates, suggesting the usefulness of this gene for identification of this species.

Diversity of ace, a gene encoding a microbial surface component recognizing adhesive matrix molecules, from different strains of Enterococcus faecalis and evidence for production of ace during human infections.

Our previous work reported that most Enterococcus faecalis strains adhered to the extracellular matrix proteins collagen types I and IV and laminin after growth at 46 degrees C, but not 37 degrees C, and we subsequently identified an E. faecalis sequence, ace, that encodes a bacterial adhesin similar to the collagen binding protein Cna of Staphylococcus aureus. In this study, we examined the diversity of E. faecalis-specific ace gene sequences among different isolates obtained from various geographic regions as well as from various clinical sources. A comparison of nucleotide and deduced amino acid sequences of Ace from nine E. faecalis strains identified a highly conserved N-terminal A domain, followed by a variable B domain which contains two to five repeats of 47 amino acids in tandem array, preceded by a 20-amino-acid partial repeat. Using 17 other strains collected worldwide, the 5' region of ace that encodes the A domain was sequenced, and these sequences showed > or =97.5% identity. Among the previously reported five amino acids critical for collagen binding by Cna of S. aureus, four were found to be identical in Ace from all strains tested. Polyclonal immune rabbit serum prepared against recombinant Ace A derived from E. faecalis strain OG1RF detected Ace in mutanolysin extracts of seven of nine E. faecalis strains after growth at 46 degrees C; Ace was detected in four different molecular sizes that correspond to the variation in the B repeat region. To determine if there was any evidence to indicate that Ace might be produced under physiological conditions, we quantitatively assayed sera collected from patients with enterococcal infections for the presence of anti-Ace A antibodies. Ninety percent of sera (19 of 21) from patients with E. faecalis endocarditis showed reactivity with titers from 1:32 to >1:1,024; the only 2 sera which lacked antibodies to Ace A had considerably lower titers of antibodies to other E. faecalis antigens as well. Human-derived, anti-Ace A immunoglobulins G purified from an E. faecalis endocarditis patient serum inhibited adherence of 46 degrees C-grown E. faecalis OG1RF to collagen types I and IV and laminin. In conclusion, these results show that ace is highly conserved among isolates of E. faecalis, with at least four variants related to the differences in the B domain, is expressed by different strains during infection in humans, and human-derived antibodies can block adherence to these extracellular matrix proteins.

[Hypothermia in the patients of emergency department].

In a 3-month period (January to March, 1992), patients with rectal temperature below 35 degrees C detected by an electrical rectal thermometer (Diatek, Inc, San Diego, CA) were enrolled. In addition to treatment of the underlying diseases, the patients were rewarmed with either a heating lamp (core temperature > 32 degrees C) or warm fluid intravenous infusion and/or gastric lavage (core temperature < 32 degrees C). Patients' vital signs, serum potassium, pH, initial temperature, mean weather temperature, underlying disease and outcome were recorded and compared between survivors and non-survivors. We collected 23 cases with mean age of 71.6 years and mean core temperature, 33.32 degrees C (29.4-34.9 degrees C). The diagnosis included hypoglycemia in 7 cases, sepsis in 3 cases, active TB in 2 cases, HHNK in 1 case, DKA in 1 case, UGI bleeding in 1 case, parkinsonism in 1 case, intracerebral hemorrhage in 1 case, urinary tract infection in 1 case, brain tumor post operation in 1 case, arrhythmia in 1 case, senile dementia in 1 case, COPD in 1 case and lung CA in 1 case. 12 (52%) cases died during admission. No significant difference in clinical parameters was noted between survivors and non-survivors. In conclusion, although in subtropic area, the hypothermic patients in our country cannot be overlooked. As patients are usually elder and have other diseases, the prognosis is correlated with the severity of the underlying disease. Alert, intensive care, prevention and treatment of the complications that arouse, and careful rewarming are necessary for management of such patients.

Experience of six patients with Vibrio vulnificus septicemia.

Vibrio vulnificus, a halophilic lactose fermenting vibrio, is a virulent pathogen for men and is frequently associated with overwhelming infections of areas other than the gastrointestinal tract. We encountered six cases of Vibrio vulnificus septicemia in Veterans General Hospital-Taipei over the past four years. All were admitted through the emergency room and presented with urgent conditions on arrival. The patients also demonstrated preexisting liver function impairment (either hepatic disease or chronic alcohol consumption). Five subjects had an apparent history of exposure to marine environments: one fisherman with pre-existing wounds and four others with previous consumption of poorly cooked seafood. Characteristic hemorrhagic bullous lesions were found in 5 cases. In all, 4 patients (67%) died with three of the cases within 24 hours of hospitalization. Misdiagnosis and delayed treatment were the most common causes. In conclusion, when patients present with sepsis and/or characteristic cutaneous lesions, particulously those with underlying liver disease and a history of marine exposure, clinicians should be alerted to this potentially fatal infection and should commence appropriate assessment and treatment immediately.

Overview of viridans streptococcal endocarditis: clinical analysis of 99 cases.

A total of 99 cases of viridans streptococcal endocarditis encountered during the period of 1973 and 1990 at the Veterans General Hospital-Taipei were reviewed to evaluate its prognostic factors. Applying strict clinical and laboratory criteria, 24 cases were categorized as definite, 44 probable, 23 possible and 8 likely. The symptoms were frequently subtle and atypical but initial laboratory tests gave useful indications: 69.1% with leukocytosis, 78% with anemia, 58.5% with elevation of LDH level, 88.9% with elevation of ESR value and 100% with elevation of CRP level. Furthermore, 32.4% of the cases demonstrated proteinuria and 67.4% microscopic hematuria. Seventy-three of the subjects had a history of underlying heart disease, predominantly rheumatic heart disease. Histological examination and echocardiography revealed that 51 patients suffered from vegetative endocarditis, 7 (13.7%) of whom were found to have anatomically confirmed vegetations without initial echocardiographic evidence, Vascular events were seen in 61 cases (61.6%): peripheral stigmata (32 cases), cerebral vascular accidents (17 cases), pulmonary embolism (10 cases) and others (2 cases). The overall mortality rate was 18.2%. Congestive heart failure with embolization was the most common cause of death in this group. The presence of vegetation was not well correlated with embolic events. There was no statistically significant association between the mortality and the following characteristics: age, sex, underlying heart disease, evidence of echocardiographically detected vegetations, major surgical intervention and recurrent cases except for embolic events (p less than 0.01). In conclusion, viridans streptococcal endocarditis complicated embolic events usually presented with a fulminant course and a grave outcome.

Septicemia in adults: II. Factors in prognosis.

Over the period of 2 months between October and November, 1987, 190 episodes of septicemia in adults were monitored at Veterans General Hospital-Taipei. The most common causative microorganisms were Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae and Staphylococcus aureus. The most frequent sources of infection came from intra-abdominal (gastro-intestinal as well as hepato-biliary), urinary and respiratory tract. Its overall mortality was 34.7%. Factors associated with a higher mortality from septicemia were old age, rapidly fatal underlying disease, hospital acquired infection, hypothermia, hypotension/shock, high-risk source of infection (from respiratory tract, skin/soft tissue, surgical wound or other unknown source), high-risk microorganisms (Candida species, Ps. aeruginosa or K. Pneumoniae) and inappropriate antimicrobial therapy. Identification of these factors may help early correction of reversible factors and improve its prognosis.

Ludwig's angina: an analysis of 14 cases.

Ludwig's angina remains a potentially lethal disease entity as it causes rapidly progressive airway obstruction, although the current mortality rate is low. Early surgical intervention should be carried out in severe cases which show signs of fluctuation, abscess formation or other serious complications. We report our experience with 14 cases of Ludwig's angina, 12 of which (86%) were of dental origin. Only one case was complicated with Klebsiella pneumoniae septicemia which resolved upon treatment. There were no deaths. Surgical procedures including incision and drainage and tooth extraction were performed in 11 cases (78%). Antibiotics were administered to all patients. Most of them were treated with crystalline penicillin with or without an aminoglycoside. Only one patient received a tracheostomy in this series. The number of tracheostomies or intubations carried out was much lower than in previous reports. We suggest that an aggressive antimicrobial therapy, early surgical intervention and careful monitoring of the respiratory symptoms would reduce both the need for tracheostomy and the mortality rate.

Mortality among laundry and dry cleaning workers in Oklahoma.

The mortality experience of 440 laundry and dry cleaning workers for the period 1975-81 was analyzed, using Oklahoma death certificate data. Results did not show an overall increase in total cancer, but an elevated risk was found for homicide, lung cancer, and kidney cancer. A decrease in risk was noted for ischemic heart disease and for breast cancer.